CMS updates No Surprises Act IDR rules for radiology disputes
New federal guidance from the Centers for Medicare & Medicaid Services changes how radiology practices and other healthcare providers can batch and submit payment disputes under the No Surprises Act. The latest update addresses new code-based batching criteria, a 50-line-item limit and revised cooling-off periods.
Issued Oct. 29, the guidance implements provisions of the Federal Independent Dispute Resolution (IDR) Operations Final Rule and establishes 27 radiology CPT code-range groups that can be used to batch qualifying services provided to multiple patients. The categories cover diagnostic imaging, ultrasound, radiologic guidance, mammography, bone and joint studies, radiation oncology and nuclear medicine.
Under the new framework, services qualify to be included in a batch only when they fall within the same specified code range. For example, a radiologist could batch head and neck imaging services with other services in that code range, but could not combine them with pelvic imaging or mammography services under separate ranges.
What’s more, services must be billed under the same National Provider Identifier or tax identification number, paid by the same health plan or insurer, and furnished within the required 30-business-day period. The open negotiation periods also must meet the applicable timing requirements.
For affected batched disputes with open negotiation periods beginning on or after Nov. 1, the new rules restrict dispute line items to a maximum of 50. Modifiers do not count toward that limit, although traditional CPT add-on codes submitted as separate line items do.
The cooling-off period for qualifying batched disputes will also be reduced from 90 calendar days to 30 business days. The period begins on the date a payment determination is issued and prevents the initiating party from filing another dispute involving the same item or service and opposing party during that time. However, batched disputes with open negotiation periods beginning before Nov. 1 remain subject to the 90-calendar-day period; the same goes for single and bundled disputes.
Separately, CMS is transitioning federal IDR administration to its new IDR Gateway. Beginning Nov. 13, organizations with Gateway accounts can submit key dispute forms, including notices of initiation, responses, certified IDR entity selection and payment offers. Users also will be able to access dispute records, dashboards, reports and notifications. Legacy web forms will remain available outside the Gateway during a transition period but are scheduled to be discontinued after Jan. 15, with an exception for the IDR initiation resubmission form.
For more detailed information on the update, click here.
In addition to her background in journalism, Hannah also has patient-facing experience in clinical settings, having spent more than 12 years working as a registered rad tech. She began covering the medical imaging industry for Innovate Healthcare in 2021.