Radiologists urge Medicare contractor to exempt professional component from new pay restriction
Radiologists are railing against one Medicare Administrative Contractor’s newly erected roadblock to payment for interpreting certain CT and MR imaging exams.
Noridian Healthcare Solutions is implementing a targeted review for two CPT (Current Procedural Terminology) codes after purportedly high error rates. The probe pertains to both CPT 74177 (CT of the abdomen and pelvis, with contrast) and CPT 72148 (MRI of the spinal canal and contents, without contrast).
Noridian claims providers have failed to submit sufficient documentation to support payment for these two services. However, the Radiology Business Management Association and American College of Radiology are now asking the Medicare contractor to exempt the professional component from these new requirements.
They note that Noridian is requiring radiologists to provide medical records “they do not control,” and are unable to force referring physicians to furnish.
“In many cases, the ordering physician, who is the custodian of the patient’s medical records, has failed to cooperate with the radiology group to provide the additional documentation requested by Noridian,” RBMA and ACR leaders wrote to the Fargo, North Dakota-based contractor on March 24. “When ordering clinicians do not supply these materials, radiology groups cannot comply, resulting in claim denials despite their best efforts.”
The American College of Radiology also highlighted this issue in a news update to its members, published March 26. In their letter, the two trade groups said the new restrictions apply to Medicare Jurisdiction E, which includes California, Hawaii, Nevada and other U.S. territories. Since implementation, ACR said it has received reports from radiology groups of “major challenges meeting documentation requests for the professional component of these exams.”
Ongoing denials have exposed radiology practices to further negative actions, which have included prepayment reviews and reimbursement suspensions.
“These risks create substantial operational and financial uncertainty,” the two associations added. “As a result, hospital-based radiology groups are concerned that continued audit rounds with elevated error rates may threaten their ability to bill and be reimbursed,” they added.
Meanwhile, RBMA and ACR said Medicare appears to be paying the technical component for these two exams without any prepayment review. This has resulted in the technical portion being considered “reasonable and necessary” while the professional portion covering a radiologist’s read is denied. Multiple radiology groups have now reported experiencing problems with payment for these two exams, the associations added.
Tom Greeson—former counsel for the ACR and long-time attorney to radiology practices—also highlighted this issue in a blog post published Tuesday. He noted that Noridian already has issued a negative response to their concerns, with the specialty now evaluating next steps to continue advocating for change. Other MACs are implementing similar such payment policies, creating added urgency.
“Thus the stakes of such prepayment reviews are significant,” Greeson wrote March 31. “A better approach would preserve program integrity while aligning with real-world clinical workflows—and would avoid unintended consequences for hospital-based radiologists and patient access,” he added later.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.