Two areas where the Centers for
Medicare and Medicaid Services are reducing reimbursement are services provided
at certain hospital outpatient departments and imaging that still uses film.
However, CMS has no simple way to automatically know which services were
performed in hospital outpatient departments that qualify for the cut and which
imaging was film-based. Instead, it is counting on coders to tell it which
claims need to have the reimbursement reduced through the use of two new
modifiers and an existing modifier with a new definition. Meet you PN, PO and
“Basically, we have to tell Medicare
to pay us less money,” said Melody W. Mulaik MSHS, CRA, FAHRA, RCC, CPC, CPC-H,
president of Coding Strategies, during an April 24 presentation at the 2017
RBMA PaRADigm conference in Chicago.
The PN modifier is the first new
modifier in the lot. It must now be applied to all non-excepted services
provided at an off-campus, outpatient, provider-based department of a hospital
and triggers an automatic 50 percent reduction in payment from the ambulatory
payment classification (APC). This applies to the technical component of
imaging, but not the professional component (the radiologist’s read).
“The 50 percent reduction is somewhat
arbitrary, which is why you will probably hear a lot more about this,” Mulaik
The second modifier is the PO
modifier. It is an existing modifier but has a new definition for 2017 and must
now be applied to all claims for services provided at an off-campus,
outpatient, provider-based department of a hospital that is exempt from the payment reduction for
reasons such as being within 250 of the hospital or being a provider-based
department grandfathered in because it began billing services prior to Nov. 2,
2015, when the rule creating the payment reduction was put into place. It is
the modifier that needs to be added if you are not using the PN modifier for
hospital outpatient department imaging.
The final new modifier is the FX
modifier and it must be put on claims for imaging that was film-based and not
digital. Nearly all imaging is now digital, of course, but when film is used,
this modifier must be added so that the reimbursement on the claim can be
automatically reduced 20 percent as required by the Consolidated Appropriations
Act of 2016.
More changes are likely coming as CMS
moves to reduce reimbursement for computed radiography (CR) by 7 percent
starting next year. Guidance for this change is not yet out, but Mulaik’s guess
is that it will involve yet another modifier that must be added to claims to
signal that payment should be reduced.
The new modifiers and the many other
coding related changes coming from CMS highlights why continuing education is
so valuable for radiology coders. In 2017, RBMA stepped up to create a special
coding education track at the PaRADigm conference in Chicago. Plans are for
this to continue in 2018. For more details on coding education resources
through the RBMA, visit. from rbma.org/coding.