Clinical 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.
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Packaging The 2010 Proposed Rule for HOPPS continues the packaging (bundling) of add-on procedures such as MR guidance for biopsy and 3D reconstruction. Contrast agents also continue to be bundled in 2010.
Procedure reimbursement For CY 2010, most medical imaging procedures will show (very) modest increases. The following chart illustrates the proposed national unadjusted rates for 2010 compared to the national unadjusted rates for 2009 for BMRI.
Addendum and additional information on the proposal can be found on the CMS Website at: http://www.cms.hhs.gov/HospitalOutpatientPPS 2010 Proposed Rule for the Medicare Physician Fee Schedule (MPFS)
Accreditation The 2010 Proposed Rule referenced the requirements of The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), which will require accreditation for facilities reimbursed from a fee schedule by 1st quarter 2012. This accreditation will apply to facilities providing “advanced imaging procedures”; these advanced imaging procedures include all of CT/CTA, MIR/MRA and ultrasound. CMS will publish a notice to solicit applications from entities (e.g., ACR and ICA) for the purpose of becoming a designated accreditation organization by November 1, 2010.
Contrast agents Contrast agents will continue to be reimbursed at Average Sales Price plus 4% in CY 2010.
Conversion Factor In CY 2010, CMS has set the conversion factor (CF) for the MPFS at $28.3208, a decrease of 21.5% from the 2009 CF of $36.066. This reduction is mandated by the Sustainable Growth Rate formula and this cut will take effect unless Congress overrides the implementation as they have in past years. The SGR was created in 1997 as a means to control the growth of Medicare expenditures with the theory being that if physician costs grew at a rate faster than the payment system could afford, they would retroactively give the money back the next year in the form of compensating fee reductions.
The SGR rate is so great this year due to the fact that Congress never enforced the cuts and each year, cuts were overridden. With each override the cuts did not go away, but were simply shelved to be enacted at a later date.
With regard to the SGR, CMS has proposed removing drugs and biologicals from the calculation of allowed and actual expenditures used in the SGR formula. The actual impact on medical imaging would be:
-11 percent for radiology
-19 percent for radiation oncology
-10 percent for interventional radiology
-13 percent for nuclear medicine
CMS has also proposed to change the equipment utilization rate from current 50 percent to 90 percent for all imaging equipment priced over $1 million. The higher the utilization, the lower the agency can set its reimbursement.
“The current payment rates assume that a physician who owns this type of equipment will use it about 50 percent of the time, but recent survey data suggest this expensive equipment is being used more frequently. As the use of this type of equipment increases, the per-treatment costs for purchasing, maintaining and operating the expensive equipment declines, making a reduction in payment appropriate.” CMS press release on the increase.
CMS used Medicare Payment Advisory Commission (MedPAC) utilization data that has been criticized as “inaccurate and flawed” by groups such as the American College of Radiology (ACR) and the Radiology Business Management Association (RBMA) for not recognizing geographic utilization patterns.
to most hospital outpatient services. The highlights of the Final Rule as related to the conversion factor areThe conversion factor is used to determine the payment amount for services provided by the hospital outpatient each year and any increase in the conversion factor will result in an increase :
2009 the conversion factor will be $66.059 (an increase of 3.6% over the 2008 CF of $63.694)
Hospitals that fail to meet the requirements of the Hospital Outpatient Quality Data Reporting will receive a reduced conversion factor of $64.784
The 2009 National Unadjusted Rates for BMRI are:
C8906 MRI with contrast, breast; bilateral $427.41
C8907 MRI without contrast, breast; bilateral $348.06
C8908 MRI without followed by with contrast, breast; bilateral $538.70
These rates are all increases from the 2008 National Unadjusted Rates.
Packaging and Bundling
The 2009 Final Rule continues the packaging and bundling for certain services into a single payment create incentives for providers to be efficient and for hospitals to utilize flexibility in managing their resources. Bundling refers to multiple, significant procedures related to an outpatient encounter or episode of care that is bundled and paid a single Ambulatory Payment Classification (APC) amount.
CMS continues the packaging approach for a number of items, including imaging guidance (CT, MR, stereotactic and ultrasound), 3D reconstruction, diagnostic radiopharmaceuticals and contrast agents (CT and MR).
This packaging will affect how procedures related top BMRI are reimbursed in 2009. CPT codes 76377, 77021 and A9579 will not be separately reimbursed in this patient setting.
In a composite APC, Medicare pays a single rate for a service which is described and reported with a combination of HCPCS codes on the same date of service (or different dates of service) rather than continuing to pay for the individual services under service-specific APCs.
CMS is establishing five imaging composite APCs based on the families of codes used for the multiple imaging procedure payment reduction policy under the Medicare Physician Fee Schedule. These composite APCs, provide a single APC payment when two or more imaging procedures using the same imaging modality were provided in a single session, would encourage imaging efficiencies under the HOPPS.
For example, if a “with and without MRI” are reported together, they are paid at the higher with contrast payment category. If they appear alone on a claim, they are paid separately as a standalone study. This new policy is intended to encourage imaging efficiencies, similar to the multiple procedure reduction currently implemented in the physician office and Independent Diagnostic Testing Facility (IDTF) setting.
The multiple imaging composite APCs for CY 2009 are:
Due to the way BMRI procedures are performed, this will not affect how these procedures are reimbursed in 2009.
The 2009 Conversion Factor will be $36.0666, an increase of 1.1%. The Medicare conversion factor is a scaling factor that converts the geographically adjusted number of relative value units (RVUs) for each service in the Medicare physician payment schedule into a dollar payment amount.
The increase will affect s all BMRI and related procedures (3D reconstruction, imaging guidance and biopsy) in this patient setting.
Contrast Media Reimbursement
CMS will continue to pay separately for drugs and biologicals including MR contrast at 106% of the average sales price (ASP+6), updated on a quarterly basis. MR agents used in BMRI will continue to be paid based on ASP+6.
Multiple Procedure Payment Reduction (MPPR)
The MPPR applies when two or more procedures within one of 11 imaging code families are furnished on the same patient in a single session. The Technical Component (TC) of the highest priced procedure is paid at 100 percent and the TC of each subsequent procedure is paid at 75 percent (a 25 percent reduction). The reduction does not apply to the Professional Component (PC).
For 2009, CMS has expanded the MPPR list by ten codes and has removed CPT code 76778 (Ultrasound, transplanted kidney, B-scan and/or real time with image documentation, with or without duplex Doppler study), a deleted code, from the list.
Due to the way BMRI procedures are performed, this will not affect how these procedures are reimbursed in 2009.
Independent Diagnostic Testing Facilities (IDTFs)
The majority of the new requirements for IDTFs in the 2009 Proposed Rule have postponed allowing more time for CMS to review comments. Until that review is complete, IDTFs are to comply with requirements set forth by Section 135 of the Medicare Improvement for Patients and Providers Act (MIPPA). This section requires accreditation for those entities furnishing advanced diagnostic testing procedures which include diagnostic magnetic resonance imaging, computed tomography, and nuclear medicine, and other such diagnostic testing procedures by January 1st 2012.
BMRI procedures performed in this setting will require accreditation to be reimbursed by Medicare by January 1st 2012.
Effective January 1, 2009, all mobile entities providing diagnostic testing must enroll in the Medicare program as IDTFs and bill the program directly for all services furnished to Medicare beneficiaries. One exception is that the direct billing requirement does not apply if the mobile supplier has a documented arrangement with a hospital to provide testing services to inpatients and outpatients of the hospital. Documentation of "under arrangements" services by mobile IDTFs to hospitals must be provided to CMS for initial and ongoing enrollment purposes. According to the commentary, these new billing/enrollment provisions apply to all mobile entities who lease equipment and technicians to other Medicare enrolled suppliers and providers, including physician practices. Although not specifically stated in the rule or preamble, this may include mobile entities leasing equipment only, irrespective of whether the services are furnished in a mobile or fixed base location. Further, the owner of a mobile IDTF has the responsibility to ensure the mobile IDTF meets all applicable regulatory obligations required under Medicare, which will be verified through the Medicare enrollment process.
The effect of the new standard is that mobile IDTFs can no longer sell diagnostic tests provided to Medicare beneficiaries to a physician group, and for which the physician group would then bill. Previously, for example, physician groups may have been able to refer and bill Medicare for certain mobile unit services under the in office ancillary services exception, by relying on the centralized building definition under Stark. For CY 2009, the new mobile IDTF billing requirement will eliminate that option for services provided to Medicare beneficiaries. However, since mobile IDTFs are currently excluded from the prohibition on the sharing of a practice location with another Medicare enrolled individual or organization, it may still be possible for the mobile IDTF to lease to the group the mobile unit and/or staff with the group billing for non-Medicare/private pay diagnostic services.
77058 MRI, Breast without and/or with contrast media, unilateral
77059 MRI, Breast without and/or with contrast media, bilateral
if you are doing a biopsy, add
77021 Magnetic resonance guidance for needle placement (e.g., biopsy, needle aspiration, injection, or placement of localization device), radiological supervision and interpretation
add the type of biopsy
19100 Biopsy of breast; needle core (surgical procedure only)
19101 Biopsy of breast; open, incisional not using imaging guidance
19102 Biopsy of breast; percutaneous, needle core, using imaging guidance
19103 Percutaneous, vacuum assist, using imaging guidance
other add-ons, if performed
19290 Preoperative placement of needle localization wire, breast
19291 Each additional lesion (Use in conjunction with 19290 only)
19295 Image guided placement, metallic localization clip, percutaneous, during breast biopsy. (Use in conjunction with codes 19102 and 19103)
Always bill the MR contrast
A9579Gadolinium based MR contrast NOS, 1mL (i.e. Magnevist, ProHance®, Omniscan™, Optimark®)
Magnetic resonance imaging (MRI) of the breast is proven for the following patients with breast implants:
to evaluate a patient with a breast implant in whom screening mammography is contraindicated or inconclusive,
to identify a breast implant rupture when screening ultrasound indicates rupture in an asymptomatic patient,
to identify a breast implant rupture in a symptomatic patient whose ultrasound does not indicate rupture, or
to diagnose local cancer recurrence in patients who have undergone mastectomy and reconstruction with implant
Magnetic resonance imaging (MRI) screening of the breast is proven for the following:
to evaluate patients with a high genetic risk of breast cancer, as determined by identification of the BRCA mutation;
to evaluate untested first degree relatives of a BRCA carrier;
to evaluate women with a lifetime risk of 20% or greater as determined by models that are dependent upon family history;
to evaluate women who have had previous radiation to the chest between ages 10 and 30;
to evaluate women and their first-degree relatives with the following defined syndromes: Li-Fraumeni syndrome,
Cowden syndrome and Bannayan-Riley-Ruvalcaba syndrome MRI screening of the breast is unproven for the following:
to evaluate women with a lifetime risk of less than 20% as determined by models that are dependent upon family history
to evaluate women with lobular carcinoma in situ (LCIS) or atypical lobular hyperplasia (ALH)
to evaluate women with atypical ductal hyperplasia (ADH)
to evaluate women with heterogeneously or extremely dense breasts on mammography
to evaluate women with a personal history of breast cancer, including ductal carcinoma in situ (DCIS) due toinadequate clinical evidence of safety and/or efficacy in published, peer-reviewed medical literature
Accreditation as a pre-requisite to reimbursement continues to be an issue in medical imaging, with the following payers having current or future effective mandates :
Highmark Blue Cross Blue Shield of Pennsylvania
Anthem Blue Cross Blue Shield of Virginia
Anthem Blue Cross Blue Shield (Indiana, Kentucky, Ohio)
Blue Cross Blue Shield of Kansas City
Care Core National
Oxford Health Plans
United Healthcare Wisconsin
Best Practices of Breast MR Accreditation
United Healthcare’s decision to require MRI accreditation (initially by March 1st 2008) is just the tip of the iceberg, with many other private payers reading accreditation programs. Centers that offer breast MRI procedures on dedicated BMRI equipment are in the process of gaining accreditation from the Intersocietal Commission on the Accreditation of Magnetic Resonance Labs (ICAMRL), the group that has been accrediting MRI facilities for the past decade.
Initiating the accreditation process is easy, if your facility follows the best practices of other facilities that have been successfully accredited for BMRI. At this time, all applicants have passed on their first attempt — the odds of accreditation are in your favor.
In order to make the accreditation process as painless as possible there are a few things that you need to do — the first being to designate someone in your facility to be the point person for the project, one person that will accept responsibility for the project and give that person the support needed to accomplish the task. Once the point person is named, follow these steps to accreditation :
Get help from the expert
Mary T. Lally, RT(R), (MR), the technical director at ICAMRL, has been very proactive in assisting dedicated BMRI sites in obtaining accreditation and she recommends facilities contact her prior to getting started. She can reached at:
Lally or phone: 410.872.0100/toll free: 800.838.2110
The ICAMRL also presents Accreditation on Demand webcasts that are free and available 24 hours daily from any computer; topics include :
Preparing Your Staff and Facility For Accreditation
Do Your Protocols Meet The Minimum Requirements?
QA/QC and Accreditation: Documenting Your Laboratory’s Accuracy
Are All Of Your Final Reports Complete And Accurate?
Case Studies: Documenting Your Proof of Quality
Get the materials by visiting www.icamrl.org
View and print out the Standards
Laboratory staff members involved with the process should read through the Standards closely, making necessary modifications to the laboratory’s operations prior to beginning work on the application. The entire MR application is now online on the ICAMRL’s secure server.
Construct a timeline
Once the point person has spoken with Mary Lally at ICAMRL, they should develop a timeline with the critical stages of the process mapped out, with key dates such as when all CE/CME will be finished, when all protocols will be drafted, when cases will be pulled for submission and the submission date your facility is aiming to meet. It is important to remember that accreditation can takes time — once your application is received by the ICAMRL staff, the process takes from sixteen to twenty weeks. Deadlines for applications are on the first day of each of the following months, January, April, July, and October.
A facility that wants to be accredited by May must have their application in by January 1st and those applications that come into the ICAMRL offices after the first day of the quarter will be reviewed in the following quarter.
Put your best effort into the process
Make sure that all components of the application are completed to the very best of your abilities — submit all the information that is requested, double-check that the case studies you are submitting meet the requirements, have all the required continuing education for physicians and technologists.
Await the accreditation decision — this is the hardest part of the process!
Contact Reimbursement Support at 888 900 BMRI to discuss how to get started with the accreditation process
Care Core National
National Imaging Associates (NIA)
Blue Cross and Blue Shield
American Imaging Management (AIM)
National Imaging Association (NIA)
Cigna for Health Care Professionals
Great West (Owned by Cigna) See Cigna
Interactive Voice Response (IVR) System
Oxford Health (Owned by United) See United
PacifiCare (Owned by United) See United
Pre-certification by various RBMs including Care Core National and National Imaging Associates
All MR procedures must be certified via the United Healthcare Radiology Notification Program
RBM Contact Information :
1. AIM Call Center at 877-291-0360
3. Humana 800 523 0023
4. NIA http://www.radmd.com/