When Worlds Collide: Integrating Radiology and Cardiology Imaging

by Cat Vasko

On August 24, 2008, Good Samaritan Hospital, Vincennes, Ind, became the first site in the country to go live with integration between the Synapse PACS from FUJIFILM Medical Systems USA Inc, Stamford, Conn, and the cardiovascular image and information system (CVIIS) from FUJIFILM’s subsidiary, ProSolv Cardiovascular, Indianapolis. FUJIFILM first announced the availability of integration between the two systems at last year’s RSNA meeting.

“We’ve had the Synapse PACS in place for several years, and we implemented the cardiovascular system about two years ago, before Fuji had purchased ProSolv. We didn’t know then that the two were going to meet at the end of the road.”
-Julie Thomas, director of cardiology Good Samaritan Hospital, Vincennes, Ind

Good Samaritan initially implemented the ProSolv CVIIS to bring its echo/vascular exams online; until then, they were still being viewed, distributed, and stored on VHS tape. Over the next two years, however, the cardiology department would gradually begin to bring most of its major modalities onto the cardiovascular system. “We knew we needed a product that could serve as a long-term storage solution for cardiac catheterization, echocardiography, peripheral vascular disease, ECGs, and stress tests,” Thomas explains.

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The Usual Suspects

by Curtis Kauffman-Pickelle

As I read the cover story on radiology benefit managers (RBMs) in this month’s Diagnostic Imaging (DI) magazine, I ruminated on the (metaphorical) similarities between the mug shots of what the author described as imaging’s new decision makers (the five reigning RBM CEOs) and the ensemble cast of Kevin Spacey’s classic film of intrigue. Which of these suspects, though, is cultivating the mystery? Which is perpetuating the myth? Which is the one most feared? Which is the inventor of the much-maligned concept of prior authorization?

It’s interesting that the Wall Street Journal (WSJ), in its November 6 edition, ran a similar prior-authorization story, Insurers Hire Radiology Police to Vet Scanning, in which the author went even further in opening up, for full view, the business model of utilization-management companies, which are exerting significant control over the medical imaging profession. The irony of the radiology police moniker in the WSJ piece, and the DI command-and-control positioning for RBMs in its article, is worth contemplating, considering the impact of these watchdogs’ revenue model on the business of radiology. Whose business do they care about most?

Although the WSJ article did discuss the fact that payors are concerned (rightfully) about overutilization and inappropriate utilization of imaging, the basic theme of the piece can best be summed up in an opening paragraph: “Some doctors say the RBMs’ review procedures can result in delays or rejections that sometimes pose risks for patients. Doctors also complain that the procedures waste their staffs’ time and force physicians to justify decisions to reviewers who haven’t seen their patients.” The article goes on to outline some cases where patients have suffered as a result of this preauthorization process, which one person characterized as a whole bureaucracy.

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Retail Metrics: Opportunity Knocks Every Time the Threshold Darkens

by Steve Smith

When a customer walks in the door, Mark Schulein sees opportunities. The first opportunity is to create an experience so memorable that the customer will not only want to return, but will also be inspired enough to tell family and friends about the visit. Second, he sees numbers. For Schulein, each customer is a chance to apply a series of metrics that are carefully watched in order to plan course corrections that will have an impact on the future results.

Schulein does not have a medical office. In fact, he didn’t even go to medical school. Schulein is the president of Crown Ace Hardware, a successful 16-store hardware enterprise, with locations in two states, that is the largest Ace Hardware chain in the western United States.

Crown has been successful, in spite of intense competition from much larger companies, partly because Schulein and his management team have remained nimble and partly because they are constantly watching numbers.

Those customer numbers include:

• the average ticket, which is the average dollar amount that each customer will spend in a particular store during a visit;
• the number of tickets (or transactions), which determines the level of customer visits;
• the overall sales per store on a month-over-month, year-over-year basis; and
• employee productivity, which helps determine the level of staffing required in each store.

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Regulatory Report: Gains Made in Campaign to Limit Self-referral

by Howard B. Fleishon, MD, MMM

Organized radiology has been devoted to the self-referral issue for more than a decade. Early literature that documented increased physician referral rates for diagnostic imaging when there is a financial incentive led to the Stark laws in the 1990s. Entrepreneurs, venture capitalists, and some medical specialties, however, have exploited opportunities either in the non-Medicare population or by taking advantage of safe harbors in the law, the largest of these being the in-office exemption.

Despite frustrating moments, there are signs that legislators, regulators, and even insurers are finally taking notice. It is useful to take a look back at 2008, review what has transpired, and consider what we may anticipate for 2009.

On the federal front, the ACR lobbying team was successful in getting significant provisions included in the Medicare Improvement for Patients and Providers Act (MIPPA), which averted the 10.5% physician-payment cut mandated by the Sustainable Growth Rate (SGR) rules. These provisions include mandatory accreditation for MRI, CT, PET, and nuclear medicine by 2012 (with private accrediting bodies being named by 2010) and the implementation of an appropriateness-criteria demonstration project to gather and analyze data at the point of ordering and the point of service.

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Negotiating for Better Reimbursement

by Kris Kyes

Negotiating higher reimbursement is nearly always possible, according to Penny Noyes, president and CEO, Health Business Navigators, Bowling Green, Ky. She presented Payor Contracts: Strategies to Analyze and Negotiate Improved Payor Reimbursement on October 21, 2008, in San Diego, at the annual conference of the Medical Group Management Association.

Noyes emphasizes that it is a mistake simply to accept whatever a commercial payor offers as its standard fee schedule, even though insurers may claim that they have set those fee schedules because they do not negotiate with individual practices and physicians. Her message, she says, is that it is imperative to negotiate in order to protect income. She covers not how to negotiate, but why, when, and using what ammunition.

The real incomes of physicians are declining, Noyes says, and this becomes obvious once those incomes have been adjusted for inflation. While the average incomes of professional and technical workers of all kinds increased about 7% between 1995 and 2003, according to the US Bureau of Labor Statistics, physicians’ incomes decreased during the same period. For all physicians, the average decrease was 7%, but this represents declines ranging from 2% for specialists to 10% for primary care providers. Reimbursement levels that are dropping (or, at best, remaining flat) are the primary reason for these income losses among physicians.

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Packaging Versus Bundling: Let the Battle Begin

by Melody W. Mulaik, MSHS, RCC, CPC, CPC-H, PCS, FCS, ACS-RA

There are very important differences between packaged services and bundled services. Unfortunately, many people use these terms interchangeably, which may result in incorrect coding practices (and, potentially, in lost revenue for the organization).

Packaging is a reimbursement term. It refers to the practice of making a single payment that includes payment for a significant procedure as well as for the minor ancillary services associated with the procedure. CMS frequently uses this term to define the services for which it will not provide separate payment. Even though CMS may not provide payment, however, the codes for these services should still be reported on the claim form, unless contraindicated by CPT® coding guidelines or Correct Coding Initiative (CCI) edits. It is especially important that packaged services be listed so that CMS can collect accurate data about hospitals’ costs. In addition, not all payors follow Medicare payment policies, and they may provide payment in situations where CMS does not.

The issue of packaged services arises more often for hospitals than for physicians, but there are situations in which this concept can be confusing for physician billing as well. For example, in a freestanding center/IDTF setting, some payors will provide separate payment for radiopharmaceuticals, while others consider them a packaged service and will not provide separate payment. Unless instructed in writing by your payor, you should always submit a code for a packaged service so that the true costs of delivering the service are reflected on the claim form.

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Time to Unwind, and Other Effects of the 2009 MPFS

by Lewis Lefko, JD, MPH

Few federal rules for billing and leasing of diagnostic testing equipment and technicians by mobile testing companies will require the restructuring or unwinding of many imaging arrangements prior to the end of 2008. In its payment policies under the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2009, published November 19, 2008¹, CMS issued changes to the reassignment rules related to diagnostic tests, known as the Anti-Markup provisions. The Medicare law requires CMS to impose a payment limitation on diagnostic tests where the physician performing or supervising the test does not share a practice with the physician or other supplier that bills for the test. The Anti-Markup prohibition applies to all diagnostic tests except tests paid for under the Medicare clinical laboratory test fee schedule. CMS also issued rules requiring Medicare enrollment and billing by mobile diagnostic testing services while deferring rules requiring physicians furnishing diagnostic tests to enroll as independent diagnostic testing facilities (IDTFs). CMS states the rules are aimed at eliminating abusive arrangements and curbing overutilization caused by the ordering of unnecessary tests.

The Anti-Markup payment limitation has long applied to technical components (TC) of diagnostic tests that physicians purchase from outside suppliers, such as imaging centers. In its CY 2008 MPFS rule, CMS amended the Anti-Markup provisions to apply to the TC of diagnostic tests ordered by the billing physician or other supplier when the TC is either outright purchased or when the TC is not performed in the “office of the billing physician or other supplier”. Such office space was defined as where the billing physician or other supplier regularly furnishes patient care, and for a group practice as where the group provides substantially the full range of patient care services that the group provides generally. The Anti-Markup payment limitation was also imposed on the professional component (PC) of diagnostic tests ordered by the billing physician or other supplier if the PC is outright purchased or if the PC is not performed in the office of the billing physician or other supplier. The Anti-Markup provisions for the TC or PC of a diagnostic test apply only when the billing physician or other supplier has ordered the TC. CMS issued a notice delaying the CY 2008 requirements until implementation on January 1, 2009.

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