AHRA wants CMS to clarify, change some modifier codes, appropriate use regulations in proposed 2017 rules

Members of the Association for Medical Imaging Management (AHRA), one of the biggest radiology management organizations in the U.S., said it hopes CMS can clarify and possibly change certain x-ray claim modifier, payment classification and appropriate use policies in its 2017 rules. According to the AHRA comments, deadlines certain Appropriate Use Criteria rules might be unrealistic and some claims modifier rules are confusing.

AHRA issued its public comments Sept. 6 on CMS's proposed rules for Medicare Hospital Outpatient Prospective Payment System (OPPS) and the Medicare Physician Fee Schedule (MPFS) for 2017.

AHRA’s members asked for a clarification in the MPFS’s new modifier rule, which it said was “made without any consideration of the operational and financial burden on hospitals…to implement the capital equipment, training, information systems programming, billing and audit processes.”

Specifically, the group wants to know if the XX named in the new modifier rule is a placeholder for a future modifier or if it is the true new name for the claims modifier in relation to film x-rays. AHRA also wants CMS to make it more clear whether this new claim modifier would be applicable to critical access hospitals (CAHs).

“Since CAHs do not bill through the PFS or HOPPS, it would seem that neither this XX modifier, nor the CT modifier for non-XR-29-compliant CT machines would be relevant to CAHs,” the AHRA commenters wrote.

Also in relation to OPPS, AHRA expressed concerns regarding CMS’s goal to implement Appropriate Use Criteria in imaging by Jan. 1, 2018, despite an overall supportive outlook toward the initiative.

The commenters pointed out, “AHRA strongly believes that the AUC consultation requirement should be at least 18 months after the qualified clinical decision support mechanisms (CDSMs) are finalized. If CMS does not finalize the list of CDSMs until July 1, 2017, as proposed, then ordering professionals should not be required to consult AUC until Jan. 1, 2019.”

The problem is mostly around the implementation of CDSMs before the implementation of the Appropriate Use Criteria, according to the commenters. Providers need enough time to understand and adequately implement CDSMs before they can deal with the Appropriate Use Criteria.

When discussing OPPS proposed rules, AHRA commenters brought up the same question as related to the XX modifier for film x-rays: What exactly does that mean?

The other two MPFS comments are related to insufficient payments to providers. The AHRA said two rules changing payment regulations are “unduly burdensome” and the payments resulting from the change in rules would be “insufficient” to run imaging centers and departments.

Those rules are the “site neutral” requirements of the 2015 Bipartisan Budget Act (requiring off-campus imaging facilities introduced into facilities that are already there to be paid under MPFS instead of OPPS) and the reduction of Ambulatory Payment Classifications to be reduced from 18 to 17. The commenters claimed that imaging payments under MPFS are declining and switching more categories to those payments would hurt business. Plus, they said eliminating one potential payment category from the classifications would also represent a significant reduction in payments.

The period for public comment closed Sept. 7, after two months of solicitation from CMS.