Radiology Coding Alert

Look beyond E/M to get the most out of the final rule.

At this point, you’re all too familiar with the 2021 evaluation and management (E/M) shakeup that’s currently underway. The 2021 Medicare Physician Fee Schedule (MPFS) final rule went into extreme detail breaking down how these changes will affect your practice. However, the guideline and policy changes included in the final rule extend well beyond 2021 E/M.

“The overwhelming focus for the MPFS final rule changes has been on 2021 E/M,” says Chelsea Kemp, RHIT, CCS, COC, CDEO, CRC, CEDC, CGIC, HIM Coding Specialist at Dignity Health Yavapai Regional Medical Center in Prescott, AZ. “However, there are many other important changes coming in 2021 that require careful review and preparation for any coding professional,” Kemp explains.

Specifically, there are two areas of emphasis within the final rule that radiology coders, billers, and physicians should home in on. First, you should take note of the revised rules on diagnostic testing and medical record review designed to give non-physician practitioners (NPPs) an expanded level of access and control. Next, among a host of changes to Merit-based Incentive Payment System (MIPS) measures, there’s are a few radiological measures that include a series of changes to take note of.

Round out your 2021 MPFS final rule knowledge with these two important areas of consideration.

Consider Loosened NPP Supervision Restrictions

Under the MPFS regulation at §410.32(b)(1), the Centers for Medicare & Medicaid Services (CMS) has amended the guidelines on diagnostic supervision to allow certain NPPs to perform diagnostic supervision services without a “general level of physician supervision.” In other words, NPPs are now eligible to perform and bill for specific qualifying urological diagnostic services without a physician present. Previously NPPs were allowed to order diagnostic tests, but only the patient’s physician could supervise the diagnostic testing.

“In place of supervision exclusively by the physician, a qualified NPP (typically a physician assistant) can now supervise diagnostic tests that are performed by a nurse or medical technician,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook. “Keep in mind that the NPP won’t be supervising physicians, but rather qualified staff such as registered nurses or medical technicians who are trained to perform such services, but cannot do so without required supervision,” Ferragamo explains.

The justification for such a change is based on the fact that NPPs are already eligible to perform such services under many states’ scope of practice rules. These rules were initially implemented in May 2020 as a means of easing the burden on providers during the public health emergency (PHE). Following suit with a variety of other previously “temporary” guidelines, CMS has decided to permanently implement this new diagnostic supervision policy. According to CMS, NPPs “are authorized to receive payment under Medicare Part B for the professional services they furnish either directly or ‘incident to’ their own professional services.”

CMS considers the following sets of NPPs eligible for diagnostic supervision services:

• Nurse practitioners (NPs)
• Clinical nurse specialists (CNSs)
• Physician assistants (PAs)
• Certified registered nurse anesthetists (CRNAs)

Refresher: In the 2020 MPFS final rule, CMS added further autonomy to the role of NPP by stating that both physicians and NPPs can “review and verify documentation entered into the medical record by members of the medical team for their own services that are paid under the MPFS.”

To consider: According to NP and PA CMS guidelines, Medicare pays services “at 80% of the actual charge or 85% of the amount Medicare pays a physician under the Medicare Physician Fee Schedule (MPFS).”

Note Abundance of Changes to Radiological MIPS Measures

In order to stay on top of your MIPS reporting, you should consider a few substantiative changes made to existing measures you’ll consider for applicable clinical encounters. First, take a look at quality measure 145: “Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy.”

The updated revision to measure 145 includes the following proposed changes: “Documentation: Information populating the final report may reside in a dedicated field in the electronic health record (EHR) or picture archiving and communication system (PACS), however fluoroscopy exposure dose or time should be included in the final report to be readily accessible in all circumstances.” This proposed revision for reporting criteria ensures that fluoroscopy exposure dose and/or time be included in the dictation report in order to report code G9500 (Radiation exposure indices, OR exposure time and number of fluorographic images in final report for procedures using fluoroscopy, documented).

Next, have a look at a revision to the reporting instructions for MIPS measure 195: “Radiology: Stenosis Measurement in Carotid Imaging Reports.” With respect to radiology, this measure is reported for patients receiving a computed tomography angiography (CTA) or magnetic resonance angiography (MRA) of the neck in addition to a duplex scan of the extracranial arteries. The change to the final rule indicates that this performance measure is to be reported exclusively for patients 18 years and older.

Lastly, you want to take into account a key change to measure 364: “Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines.” According to the Centers for Medicare and Medicaid Services (CMS), you will report quality measure 364 for a “Percentage of final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians).”

However, the final rule includes an underlying change of guidance on which pulmonary findings you should not include as “incidental findings in the context or intent of this measure.” Specifically, when considering reporting measure 364, CMS advises that you should not consider “granulomas, hamartomas or lesions with internal fat, or other characteristically benign findings” as incidental findings as they pertain to this quality measure. CMS explains that the underlying reason for this change is to distinguish between findings that are “widely known to be benign and would therefore not necessitate a specific documentation of a recommendation of no follow-up.” For other findings that include a pulmonary nodule that the radiologist deems incidental, you may report the respective HCPCS Level II code indicating performance met status or denominator exception.