• Why Aurora Breast MRI
• Product Overview
• Medical Education
• SpiralRODEO™ Sample Images
• Advisory Board
• Clinical Case Studies
• Testimonials

• Reimbursement
• Siting Requirements
• Company Overview
• Aurora News & Events
• Aurora Locations
• Contact Us

Breast MRI Procedure Reimbursement

For many practices today, barriers to payment are sometimes merely a lack of accurate billing tools. In today’s data access environment, reimbursement is primarily driven by historical data. When practices do not have access to appropriate coding and coverage guidelines, they don't have the correct tools to report procedures, resulting in reimbursement issues.

Aurora Imaging Technology, Inc. is happy to provide their customers with a Reimbursement Hotline Support.  This service provides customers with:

• New Account Billing Assistance
• Reimbursement Hotline to Answer Questions
• State Specific Billing Guides
• Information and Guidance on Accreditation

Reimbursement support can be accessed by calling the Aurora Reimbursement Hotline at (301) 371-3449 or emailing your requests to bossias@auroramri.com.

Accreditation as Pre-requisite for Reimbursement/the United Healthcare Mandate

2008 Medicare Coverage and Reimbursement for Breast MRI Procedures

CMS 2008 Final Rule for the Hospital Outpatient Prospective Payment System (HOPPS)

2008 Final Rule for the Medicare Physician Fee Schedule

Non-Medicare Payers

Coding for BMRI and Related Procedures

Accreditation as Pre-requisite for Reimbursement/the United Healthcare Mandate

United Healthcare has informed participating providers that starting third quarter 2008 (originally the date had been March 1st), for outpatient imaging studies billed on the CMS 1500 claim or the electronic equivalent, the facility must be accredited for the following procedures: CT, CTA, MRI, MRA, Nuclear Medicine/Cardiology, PET, and Echocardiography. This mandate includes breast MRI and at present there is only one accrediting body that will accredit dedicated breast equipment, the Intersocietal Commission on the Accreditation of Magnetic Resonance Laboratories (ICAMRL). Mary Lally, the technical director of the ICAMRL, can provide information on how to apply for accreditation for breast MRIs performed on dedicated breast scanning equipment and can be reached at lally@intersocietal.org. You can also contact Aurora Reimbursement Support for assistance in getting started: bossias@auroramri.com.

Failure to obtain accreditation by third quarter 2008 will affect providers' ability to be reimbursed for procedures rendered using these modalities. This accreditation protocol is to ensure that freestanding, outpatient facilities and physician offices that perform imaging studies meet nationally recognized quality and safety standards.

2008 Medicare Coverage and Reimbursement for Breast MRI Procedures

The 2008 Final Rules for the Hospital Outpatient Prospective Payment System (HOPPS) and the Medicare Physician Fee Schedule (MPFS) were issued last fall and became effective on January 1st 2008. 

It is important to note that, while it is a significant payer, Medicare accounts for only a small portion of the breast imaging population.

CMS 2008 Final Rule for the Hospital Outpatient Prospective Payment System (HOPPS)

In the 2008 Final Rule the majority of medical imaging procedures saw an increase over the 2007 rate;  increases only due to the packaging or bundling of add-on procedures into their related primary procedures.  Bundling of supplies, drugs and biologicals with corresponding procedures is not uncommon and CMS has been doing more bundling with add-on procedures in recent years, but in this case the increases were, for the most, not enough to cover the add-on procedure component(s). 

In order to further cost efficiencies within the HOPPS setting, CMS is extending bundling to include guidance services, image processing services, intra-operative services, imaging supervision and interpretation services, diagnostic radiopharmaceuticals, contrast agents, and observation services.  CMS has the theory that these groups of supportive ancillary services are integral to the performance of primary diagnostic and treatment procedures, so that packaging payment for these additional services results in larger payment bundles that will provide hospitals with the flexibility to manage their resources efficiently.

The seven categories of supportive ancillary services that CMS has deemed integral to the performance of primary diagnostic and treatment procedures and therefore are being bundled into the primary diagnostic or treatment procedure with which they are performed are:  

• Guidance services including MR guidance
• Image processing services
• Intra-operative services
• Imaging supervision and interpretation services
• Diagnostic radiopharmaceuticals
• Contrast agents including MRI
• Observation services

Examples of the increases are:

While the increases looked good at first glance, they do not cover the revenue lost in not being paid separately for the add-ons.  In 2007 two add-on procedures for BMRI are paid at the following national, un-adjusted rates:

Computer Aided Detection for all breast procedures is not reimbursed in the 2008 Final Rule.  This includes 0159T (CAD for BMRI) and 77051/77052 (CAD for mammography). 
The 2008 Final Rule can be found at http://www.cms.hhs.gov/HospitalOutpatientPPS/.   It will be published in the Federal Register on November 27, 2007.

2008 Final Rule for the Medicare Physician Fee Schedule

The significant highlights of the 2008 Final Rule for the Medicare Physician Fee Schedule include:

• Reduction in Payment for Physicians Services

The proposed rule included an update required by the sustainable growth rate (SGR) methodology, which was to result in a negative 9.9% update, actually a decrease, in Medicare payments, noting that Congress has intervened to eliminate the negative update or decrease for each of the last five years.

The 2008 Final Rule included a 10.1 percent cut in the conversion factor for physician-related services which is required by law under the Sustainable Growth Rate formula (SGR). CMS was required to implement this negative update by Jan. 1, 2008, but on December 28th Congress passed legislation negate this cut until July 1st and even add an additional 5%.

• The Deficit Reduction Act

The 2008 Final Rule addresses continued implementation of the Deficit Reduction Act (DRA) payment caps for the technical component of diagnostic imaging services provided in the freestanding facility setting.  That said, there are issues with implementation such as the fact the several procedures subject to DRA reduction in 2007 are now bundled in the HOPPS Final Rule and in CY 2008 will have no technical component payment to tie the Part B Fee Schedule to.  For those procedures, CMS states: "If an imaging procedure is packaged under HOPPS, the DRA cap on the technical payment for that service under MPFS is not applicable."  CMS further states that "where there is no HOPPS payment for a procedure or where the HOPPS for a procedure is bundled, there is no HOPPS amount for comparison with the MPFS payment. Therefore it is infeasible to apply an HOPPS cap.  The codes will remain on the list of codes subject to the HOPPS CAP, but will not be affected by the cap."  In CY 2007 we have seen DRA reductions applied to add-on procedures 3D Reconstruction (billed with CPT code 76377) and MRI guidance for breast biopsy (billed with CPT code 77021), procedures that are now bundled into the corresponding primary procedure in the hospital outpatient setting under HOPPS.

In December when Carriers posted the 2008 Physician Fee Schedules Aurora Reimbursement Support staff conducted a Carrier-by-Carrier review to determine which procedures are capped to the HOPPS amount and BMRI and related procedures are not capped on any fee schedule..

• Changes in the Practice Expense

In 2008 changes to the radiology practice expense per physician hour amount to a nearly $100 million shift in overall practice expense dollars to radiology. While not a huge increase in radiology’s practice expense values this is significant because it based on data collected by the American College of Radiology for determining the practice expense formula. The increase in radiology’s practice expense per physician hour from $174 to $204 is a result of the ACR survey data collected on practice costs.

This rule continues the second year of a new methodology for determining practice expense (PE) (such as office overhead) RVUs with a 50% phase in CY 2008, with the new methodology to be phased in over a four year period. CMS will apply a 75% phase in CY 2009 and full implementation in 2010.  The impact to MRI, with procedures carrying higher equipment costs, the rates will increase over time, and other procedures with lower equipment expenses will see reductions.

Two other important notes regarding the PE methodology calculations: (1) CMS has not changed the equipment usage percentage assumption of 50%, and (2) CMS has not changed the equipment interest rate assumption, maintaining it at 11%.

• Other Provisions in the 2008 Final Rule

The rule contains several other provisions affecting medical imaging, including:

Imposing an anti-markup restriction on the technical component or professional component of diagnostic imaging tests (including nuclear medicine tests) that are ordered by the billing provider, or purchased by the billing provider, or the technical component or professional component are performed outside of the office of the billing provider.  In the final rule, CMS states that any professional fees or technical costs negotiated for diagnostic tests that are below the payment rates in the Medicare physician fee schedule must also be the rates submitted to Medicare for reimbursement- meaning the billing provider cannot keep the balance as a profit of the negotiated arrangement.

Physician Self-Referral of Imaging Services
In the 2008 Final Rule for the Medicare Physician Fee Schedule CMS decided to not implement any of the items put forth in the MPFS Proposed Rule released in July with the exception for the anti-markup provisions for diagnostic tests discussed above. In the final rule CMS states:

“Given the number of physician self-referral proposals, the significance of the provisions both individually and in concert with each other, and the volume of public comments, we do not believe it is prudent to finalize any of the proposals in this rule. Although we are not finalizing the proposed revisions to the other physician self-referral regulations in this final rule with comment period, we are confident that we have sufficient information, both from the commenters and our independent research, to finalize revisions to the physician self-referral regulations without the need for new proposals and additional public comment. We intend to publish a final rule that addresses the following proposals:

• Burden of proof;
• Unit-of-service (per-click) payments in lease arrangements;
• The period of disallowance for noncompliant financial relationships;
• Ownership or investment interests in retirement plans;
• “Set in advance” and percentage-based compensation arrangements;
• “Stand in the shoes” provisions;
• Alternative criteria for satisfying certain exceptions; and
• “Services furnished under arrangements.”

The rule can be found at http://www.cms.hhs.gov/center/physician.asp.

Non-Medicare Payers

To confirm reimbursement rates for specific codes in your geographic locale, contact Aurora Reimbursement Support at bossias@auroramri.com.

Coding for BMRI and Related Procedures

The "C" HCPCS codes are still in effect for procedures performed in the hospital outpatient setting billed to Medicare.
There are other procedures that can be billed, if performed and properly documented, in conjunction with breast MRI.  Some of those procedures are:

*CPT codes and descriptions only are copyright © 2008 American Medical Association. All rights reserved. No fee schedules are included in CPT. The AMA assumes no liability for data contained or not contained herein.