Health policy, economics and coding

Health policy, economics and coding

Reimbursement claims and appeals

SIR and its members are dedicated to improving public health through pioneering advances in minimally invasive, image-guided therapies.

Regulatory comment letters 

CMS releases CY 2021 Final Rule for Medicare Physician Fee Schedule (MPFS)

On Dec 1, 2020, the Centers for Medicare & Medicaid Services (CMS) published the final rule for CY 2021 CMS Medicare Physician Fee Schedule (MPFS). The final rules have updated payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) scheduled to take effect on or after Jan 1, 2021. Under the current MPFS, interventional radiology services will see an 8% cut in reimbursement, and radiology will see a 10% reduction. (see Table 106).

CMS has finalized a significant budget neutrality adjustment wherein the CY 2021 physician payment conversion factor is $32.41, a decrease of $3.68 from the CY 2020 conversion factor of $36.09. This is an overall decrease of 10.2%. CMS also adopted the relative value recommendations made by the AMA/Specialty Society RVS Update Committee (RUC) for the office and outpatient E/M visits. According to the AMA, although the surgical specialties participated in the RUC survey and their data and vignettes were incorporated into the RUC recommendations, in the final 2021 E/M policies, CMS did not apply the RUC recommended values to the visits bundled into global surgical payments.

For a quick review of the upcoming changes, please review the following:

Fact Sheet for CY 2021 MPFS

CY 2021 Quality Payment Program final rule Fact Sheet and FAQs

CY 2021 CMS Medicare Physician Fee Schedule (MPFS)

Trump Administration Finalizes Permanent Expansion of Medicare Telehealth Services and Improved Payment for Time Doctors Spend with Patients

The MPFS addresses Medicare rates and policies under Part B, as well as the Quality Payment Program (QPP) value-based payment programs: Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

SIR always submits comment letters to federal agencies, CMS, and insurance carriers that specifically address interventional radiology treatments. The following comment letters are available:

  • SIR CY 2021 comments to the Center for Medicare and Medicaid Services (CMS)  proposed changes to Medicare Physician Fee Schedule (MPFS)  
  • SIR CY 2021 comments to the Center for Medicare and Medicaid Services (CMS)  proposed changes in Hospital Outpatient Prospective Payment System (HOPPS)
  • SIR CY 2020 comments to the Center for Medicare and Medicaid Services (CMS) proposed changes to the Medicare Radiation Oncology (RO) Model



Carrier/coverage letters archive

Within the last year, there have been several inquiries, from membership, regarding claim denials from Medicare contractors and private payers. SIR’s Economics Committee and Practice Development Committee devised an in-depth analysis that determined that SIR needed to strengthen its existing relationship with different carriers and their respective stakeholders. The first step in this systematic approach required a clear understanding of the core issues pertaining to claim denials or delayed reimbursements for interventional radiology procedures. The practice development committee designed the Carrier Advocacy Form, which allows all members to submit denial letters from all payers, including Medicare contractors and private carriers. 

The SIR coding and reimbursement subcommittee sent several carrier-advocacy letters on behalf of our membership to advocate for appropriate reimbursement of specific IR procedures properly. 

SIR comment letter archive 

Coverage letter templates

SIR has found that sometimes carriers deny reimbursement to the physician or the patient for specific interventional radiology treatments. The society has developed several examples of common coverage request letters. 

Learn more and download templates Submit claims denials here 

For more information on health policy, coding, and reimbursement, please contact the economics team.

Improper specialty designator for IR could impact future reimbursement

Is your practice using the right specialty code to properly capture your work as an interventional radiologist? In the Medicare PECOS system, interventional radiology has its own Medicare specialty code—Code 94.  However, many radiology groups continue to use the diagnostic radiology identifier—Code 30—for IRs.  This imprecise specialty code could negatively impact IRs as the federal government shifts to the new payment systems mandated by the 2015 Medicare Access and CHIP Reauthorization Act (MACRA).

SIR members should work with their administrators to ensure that your CMS 855 forms and PECOS enrollment are coded as Specialty 94 to ensure accurate quality reporting and payment. See the PECOS for Physicians and Non-Physician Practitioners Fact Sheet — Revised  

SIR designed the E/M toolkit to help its members with proper coding and billing of evaluation and management services. There are many more coding and reimbursement resources within the health policy page.

Learn how you are listed or for more information on health policy, coding and reimbursement, please contact Sandy Dulebohn or Miata Koroma.

Ask coding questions

Ask coding questions

Send your coding questions to SIR staff. This ensures that the details of your coding question do not get lost in translation from a phone message. 

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Understanding global periods

Understanding global periods

Medicare established a national definition of a global surgical package to ensure that Medicare Administrative Contractors (MACs) make payments for the same services consistently across all jurisdictions. SIR has prepared references to assist physicians and administrators with common global periods for codes frequently reported by interventional radiologists. 

Learn more