Dial-In Instructions

Transcription

1 Dial-In Instructions Conference Name: Scheduled Conference Date: Tuesday, April 29, 2003 Scheduled Conference Time: Scheduled Conference Duration: 1:00 pm. 2:30 pm (Eastern), 12:00 pm 1:30 pm (Central), 11:00 am 12:30 pm (Mountain),10:00 am 11:30 am (Pacific); 9:00 am 10:30 am ADT (Alaska); 8:00 am 9:30 am H/AST (Hawaii-Aleutian) 90 Minutes PLEASE NOTE: If the audioconference occurs April through October, the time reflects daylight savings. If your area does NOT observe Daylight Savings, times will be one hour earlier. Your registration entitles you to: ONE telephone connection to the audioconference. Invite as many people as you wish to listen to the audioconference on your speakerphone. Permission is given to make copies of the written materials for anyone else who is listening. In order to avoid delays in connecting to the conference, we recommend that you dial into the audioconference 15 minutes prior to the start time Dial-In Instructions: 1. Dial and follow the voice prompts. 2. You will be greeted by an operator 3. Give the operator your pass code and the last name of the person who registered for the audioconference. 4. The operator will then verify the name of your facility. 5. You will then be placed into the conference. Technical Difficulties 1. If you experience any difficulties with the dial-in process, please call the Conference Center reservation line at If you should need technical assistance during the audio portion of the program, please press the * key followed by the 0 key on your touch-tone phone and an operator will assist you. If you are disconnected during the conference, dial Q&A Session 1. To enter the questioning queue during the Q&A session, callers need to push the 1 key followed by the 4 key on their touch-tone phones. Note: This portion of the program generally falls after the first hour of presentation. Please do not try to enter the queue before this portion of the program. 2. If you prefer not to ask your question on the air, you can fax your question to or (Please note: You can only fax your question during the program.) Evaluation Form At the conclusion of the program, please return the evaluation form included with the materials package by fax to the number at the bottom of the evaluation form. If you downloaded your materials from the Internet, please print the evaluation form and fax it to the number on the bottom of the evaluation form.

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3 Mammography Regulation R E P O R T Guide to FDA Compliance, Accreditation and Better Image Quality presents... Strategies for accurate breast procedure and mammography coding A 90-minute interactive audioconference Tuesday, April 29, :00 p.m. 2:30 p.m. (Eastern) 12:00 p.m. 1:30 p.m. (Central) 11:00 a.m. 12:30 p.m. (Mountain) 10:00 a.m. 11:30 a.m. (Pacific) hcpro

4 In our materials we strive to provide our audience with useful, timely information. The live audioconference will follow the enclosed agenda. Occasionally our speakers will refer to the materials enclosed. We have noticed that other non-hcpro audioconference materials follow the speaker s presentation bullet-by-bullet, page-by-page. Because our presentations are less rigid and rely more on speaker interaction, we do not include each speaker s entire presentation. The materials contain helpful forms, crosswalks, policies, charts, and graphs. We hope that you find this information useful in the future. ii

5 hcpro The audioconference materials package is published by HCPro, Inc., 200 Hoods Lane, P.O. Box 1168, Marblehead, MA Copyright 2003, HCPro. Attendance at the audioconference is restricted to employees, consultants and members of the medical staff of the Licensee. The audioconference materials are intended solely for use in conjunction with the associated HCPro audioconference. Licensee may make copies of these materials for your internal use by attendees of the audioconference only. All such copies must bear this legend. Dissemination of any information in these materials or the Audioconference to any party other than the Licensee or its employees is strictly prohibited. Advice given is general, and attendees and readers of the materials should consult professional counsel for specific legal, ethical, or clinical questions. HCPro is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations, which owns the JCAHO trademark. For more information, contact: HCPro 200 Hoods Lane P.O. Box 1168 Marblehead, MA Telephone: 800/ Fax: 781/ Web: iii

6 hcpro 200 Hoods Lane P.O. Box 1168 Marblehead, MA Tel: 800/ Fax: 800/ Dear colleague, Thank you for participating in our Strategies for accurate breast procedure and mammography coding audioconference with Bryan Cote, Yvonne Hoiland, CPC, CPC-H, and Melody W. Mulaik, MSHS, CPC, RCC. We are excited about the opportunity to interact with you directly and encourage you to take advantage of the opportunity to ask our experts your questions during the audioconference. If you would like to submit a question before the audioconference, please send it to mmcginn@hcpro.com and provide the program date in the subject line. We cannot guarantee your question will be answered during the program, but we will do our best to take a good cross section of questions. If at any time you have comments, suggestions, or ideas about how we might improve our audioconference, or if you have any questions about the audioconference itself, please do not hesitate to contact me. And if you would like any additional information about other products and services, please contact our Customer Service Department at 800/ Along with these audioconference materials, we have enclosed a fax evaluation. We value your opinion. After the audioconference, please take a minute to complete the evaluation to let us know what you think. Thanks again for working with us. Best regards, Mark McGinn Audioconference Coordinator Phone: Ext mmcginn@hcpro.com Fax: iv

7 Table of contents Agenda vi About your sponsors vii Speaker profiles ix Continuing education credit Information x Exhibit A Presentation slides Exhibit B Program Memorandum from the Dept. of Health and Human Services 9/27/03 Subject: Coverage and Billing for Subcutaneous Image-Guided Breast Biopsy Exhibit C Articles from HCPro, Inc. Getting milked over carrier probes Digitization cometh April fools day billing rush Audits show digital coding woes E/M report: Return interpretations with breast imaging codes to referring doc, experts say Resources ASRT Attendance Sheet ASRT CE Request for Approval Form AAPC Attendance Sheet Certificate of Attendance v

8 Agenda 1. To provide proper coding for breast imaging including: diagnostic screening, mammography, and minimally invasive procedures such as breast biopsy, cist asperation, etc. 2.Coding and modifier differences between diagnostic screening and mammography 3.To show correct modifier use for breast procedures and mammography 4. Address reimbursement challenges and concerns 5. Explanation of the process of how to audit these procedure codes 6.Live Q and A vi

9 About your sponsors About HCPro, Inc., HCPro, Inc., is the premier health care information and resource provider on compliance and regulatory issues faced by hospitals, home health organizations, nursing homes, physicians offices and other health care facilities. HCPro, Inc., has launched a number of Web supersites that include tips, how-to information, Ask the Expert columns, free newsletters, and so much more. About Mammography Regulation Report The FDA has recently stepped up its enforcement of the Mammography Quality Standards Act regulations, issuing hundreds of warning letters to first-time and repeat violators. Mammography Regulation Report: Your Guide to a Successful FDA Inspection and Overall Federal Compliance will help you meet the FDA s high-quality standards. Meet the challenges of an FDA inspection Published monthly, Mammography Regulation Report is a new, 12-page newsletter focusing on the regulations that affect directors of mammography, directors of radiology, administrators, chief x-ray technologists, mammography supervisors and techs. Topics covered in Mammography Regulation Report include: Explanations of FDA regulations and advice on how to make compliance easier Reminders on staff, education, and licenses How to train new x-ray technologists to ensure they are committed to compliance from day one How to prepare for your annual FDA inspection Tips on improving mammography quality and interpretation Analysis of FDA warning letters Coding tips to ensure proper reimbursement Create phantom images Film expert advice on mammogram positioning and compression-two problem areas, according to FDA inspectors Advice from the FDA and American College of Radiology How to manage the paper trail Solutions for efficient record-keeping Updates on equipment Exclusive subscriber benefits Mammography Regulation Report is more than just a newsletter; it s a complete set of resources. Take a look at the exclusive subscriber benefits you ll receive as part of your subscription: Case studies Read about mammography facilities that have implemented innovative ways of meeting FDA regulations, and learn from their success. chat group Network with your peers about crucial safety issues through Mammo Tech Talk, our chat group. vii

10 Special Reports Whenever a hot new trend develops that requires clarification and analysis, we ll compile a Special Report and send it to you immediately. Web site referral service Our editors work hard researching the field, so you don t have to. In each issue, we ll give you the exact Web addresses for important information for your professional success. Fax Express Whenever news breaks that just can t wait until the next regular issue, we ll fax it to you immediately. Available at viii

11 Speaker profiles Bryan Cote (moderator) Bryan Cote is the managing editor of two monthly publications covering health care laws and compliance stories. He also writes a weekly electronic news update on physician practice issues. Yvonne Hoiland, CPC, CPC-H, RCC Yvonne Hoiland, CPC, CPC-H, RCC, is a senior coding consultant with Coding Continuum, Inc., a Tucsonbased consulting firm specializing in quality monitoring, compliance audits and education. In addition to her consulting work, Hoiland is licensed by the American Academy of Professional Coders to teach its Professional Medical Coding Curriculum and has taught Coding Continuum, Inc. clients as well as staff at a major teaching facility in the southwest during the last two years. Hoiland s previous work experience includes coding quality monitoring as well as staff and physician education at facilities in Idaho and Arizona. In addition, she has experience in hospital-based settings, with primary emphasis on ambulatory surgery and ancillary service coding. Melody W. Mulaik, MSHS, CPC, RCC Melody W. Mulaik, MSHS, CPC, RCC. is the president and cofounder of Coding Strategies, Inc. located in Atlanta. She serves on the advisory board for the Radiology Administrator s Compliance and Reimbursement Insider and is the Technical Advisor for the Radiology Coder s Pink Sheet published by United Communications. Her areas of expertise include billing and collections, physician medical coding, management engineering, medical school relations and operations improvement. She is a nationally recognized speaker on many topics including Interventional Radiology Coding, Developing an Internal Auditing Program, Radiology Coding Compliance, Correct Nuclear Medicine Coding and other healthcare compliance issues. In 2002 her national speaking engagements included the annual conferences of the American Academy of Professional Coders (AAPC), American Healthcare Radiology Administrators (AHRA), Healthcare Billing Management Association (HBMA) and Medical Group Management Association (MGMA). Mulaik obtained a Master s of Science in Health Systems and a Bachelor of Industrial Engineering degree, both from the Georgia Institute of Technology, Atlanta. She also holds the professional certification of Certified Professional Coder and Radiology Certified Coder. ix

12 Continuing education credit information ASRT: RT Certification for live program only Description of ASRT credits for RT certification The American Society of Radiologic Technologists is a professional organization for Registered Radiologic Technicians. To become registered, an individual must complete an accredited educational program in the radiologic sciences and pass a national certification examination. Registered Radiologic Technologists are also required to earn 24 continuing education credits every two years, ensuring that they stay up-to-date with the technological changes in their profession. At least 12 of these credits must be Category A activities which are evaluated and approved by a Recognized Continued Education Evaluation Mechanism (RCEEM). ASRT is an approved RCEEM. Getting ASRT credits for RT certification by attending an HCPro, Inc. audioconference: Registered Radiologic Technologist professionals attending this ASRT-approved live audio conference program can be assured they will receive ASRT continuing education credit by adhering to the following instructions: Registered Radiologic Technologists certified by ASRT are responsible for obtaining verification of their attendance at all CE activities. Please use the Certificate of Attendance included in the Resources section of this handout to verify your attendance. You are also required to sign the official attendance sheet included in this materials package. Additionally, the ASRT requires that you provide your social security number on the attendance sheet as well. For specific questions related to your certification, please contact ASRT directly by using the following information: American Society of Radiologic Technologists Department of Education Central Ave SE Albuquerque, NM Telephone: 800/ Web site: AAPC: CPC or CPC-H Certification Description of AAPC credits for CPC / CPC-H certification To maintain accreditation as a Certified Professional Coder (CPC) or Certified Professional Coder-Hospital (CPC- H), the American Academy of Professional Coders requires completion of 18 continuing education units (CEUs) annually. x

13 Getting AAPC credits for CPC / CPC-H certification by attending an HCPro, Inc. audioconference CPC s or CPC-H s attending this AAPC-approved audio conference program can be assured they will receive AAPC continuing education credit by adhering to the following instructions: Individuals certified by AAPC are responsible for obtaining verification of their attendance at all CE activities. Please use the Certificate of Attendance included in the Resources section of this handout to verify your attendance. Additionally, as part of AAPC s continued effort to offer the highest standard of CEU accreditation, all participants attending this audioconference are required to complete the CEU Seminar Evaluation sheet and return to AAPC at the end of the program. For specific questions related to your certification, please contact AAPC directly by using the following information: American Academy of Professional Coders 309 West 700 South Salt Lake City, Utah Telephone: 800/626-CODE Web site: xi

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15 Exhibit A Presentation slides hcpro

16 Exhibit A Mammography Codes Some of these codes are gender specific. Documentation What are the requirements? Ordering Physician Requirements Screening Mammography Screening mammograms are radiologic procedures furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer.. A doctor s referral is not necessary for the procedure to be covered How Often? One Baseline Yearly Diagnosis Coding For a screening mammogram in which no problems are detected V76.12 High risk patient in which no problems are discovered V76.11 Gender specific per Medicare Modifier -52 The codes for screening mammography are inherently bilateral. When would it be appropriate to append modifier -52? 2

17 Exhibit A Diagnostic Mammography Diagnostic mammograms must be ordered by a physician or qualified non-physician practitioner and are covered as often a medically necessary. Symptoms include breast discharge, mass, knot or lump that can be felt or pain. Diagnosis Coding There are many codes that could be used for diagnostic mammograms. Breast cancer codes are gender specific Be Careful in selection Modifier -52 When would it be appropriate to use modifier -52 for diagnostic mammograms? Other Issues to Consider How would a screening and diagnostic mammogram performed on the same date of service be coded? Other Issues to Consider Modifier -GG Other Issues to Consider What about a woman who has had breast implants? Other Issues to Consider How do we ensure that the appropriate modifiers and procedures are being charged? Does the person doing charge entry know that the patient may have had a diagnostic and screening mammography on the same date of service? 3

18 Exhibit A Auditing Have you audited your mammography s lately? What should you look for when performing an audit? 2003 Code Changes had verbiage changes Verbiage changes to the parenthetical notes under codes 78085, and How does this affect coding? Component Coding Percutaneous minimally-invasive or interventional biopsy procedures generally include both the procedure and the imaging guidance First assign the code for the biopsy procedure (FNA, core biopsy, rotating vacuumassisted device, etc.) Assign a code for the imaging guidance supervision and interpretation portion of the procedure If only the professional service, add modifier 26 to the imaging guidance code Technical component only, modifier TC Percutaneous Procedures Cyst Aspiration(s) Breast Biopsies Needle Core Stereotactic Rotating Biopsy Device Vacuum-Assisted Needle Wire Localization Clip Placement Ductogram Lymphoscintigraphy 4

19 Exhibit A Imaging Guidance - Stereotactic Stereotactic localization for breast biopsy or needle placement, each lesion, RS&I Imaging Guidance - Mammographic Mammographic localization for breast biopsy or needle placement, each lesion, RS&I Imaging Guidance - Other Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), IS&I Computerized tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), RS&I Magnetic resonance guidance for needle placement (eg, biopsy, aspiration, injection, localization device), IS&I FNA, with imaging guidance Cells obtained from non-palpable and certain palpable tissues May be performed under local anesthesia May require several passes to obtain cells Includes smear preparation Cyst Aspiration(s) puncture aspiration of cyst of breast each additional cyst For bilateral cyst aspirations, code An additional code is assigned for the imaging guidance used during the procedure: stereotactic localization guidance 5

20 Exhibit A mammographic guidance MRI guidance US guidance Breast Biopsies Biopsy of breast; percutaneous, needle core, using imaging guidance Performed on a palpable lesion percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance Performed on a non-palpable lesion and certain palpable lesions Needle Core Biopsy Multiple core samples may be collected Code assigned once per lesion Hollow core needle or spring-loaded device Needle Core Biopsy Imaging supervision and interpretation: stereotactic localization guidance mammographic guidance CT guidance MRI guidance US guidance Only physician who performs imaging guidance may code and bill Rotating Biopsy Device Large core breast biopsy (ABBI, Advanced Breast Biopsy Instrumentation) Removes large sample under imaging guidance Generally requires suture closure Has not gained wide acceptance Not approved for complete excision of a lesion 6

21 Exhibit A Vacuum-Assisted Biopsy Special biopsy probe inserted once through a skin nick As accurate as traditional open surgery; 3 times more accurate than core biopsy After probe is positioned, vacuum line draws breast tissue into sampling chamber where rotating cutting device captures tissue sample Tissue sample is carried through the probe to the tissue collection area Mammotome Breast Biopsy System Vacuum-Assisted Biopsy Imaging supervision and interpretation: stereotactic localization guidance mammographic guidance CT guidance MRI guidance US guidance Only physician who performs imaging guidance may code and bill Needle Localization Wire Placement preoperative placement of needle localization wire, breast each additional lesion Imaging supervision and interpretation: stereotactic localization guidance mammographic guidance US guidance Clip Placement Image guided placement, metallic localization clip, percutaneous, during breast biopsy (list in addition to code for primary procedure) May be assigned with biopsy codes or Bundled into wire localization code

22 Exhibit A Surgical Specimen Multiple specimens on one film = 1 study Requires separate interpretation and report Ductography, Galactography injection procedure for mammary ductogram or galactogram mammary ductogram, single duct, radiological supervision and interpretation mammary ductogram, multiple ducts, radiological supervision and interpretation To code the total procedure, assign both the injection code and an imaging study Only performed at select centers by radiologists with significant experience in ductography Lymphoscintigraphy Nuclear medicine imaging procedure that identifies lymphatic drainage pattern of a body region lymphatics and lymph node imaging Injection of radiotracer not separately coded even when performed in a separate department under ultrasound guidance This service is generally performed in the radiology department Requires written interpretation and report Lymphoscintigraphy In some cases, the nuclear medicine physician will only perform the injection of the radioactive tracer, with vital blue dye injection procedure; for identification of sentinel node No lymphoscintigraphy performed Node located using hand-held gamma probe 8

23 Exhibit A Modifier Distinct Procedural Service Indicates that a procedure or service was distinct or independent from other services performed on the same day Indicates that the ordinarily bundled code represents a service performed independently on the same date Modifier Distinct Procedural Service May represent different session or patient encounter different procedure or surgery different site or organ system separate incision or excision separate lesion separate injury not ordinarily encountered or performed on the same day by the same physician Modifier Distinct Service Documentation must be clear that a separate distinct procedure occurred May allow the code to bypass payor edits Use only if another modifier does not better describe the circumstances Mammography Codes G0202 Screening mammography; bilateral, all views G0204 Diagnostic mammography; unilateral, all views G0206 Diagnostic mammography; bilateral, all views 9

24 Exhibit A G0236 Further physician review Mammography Codes Mammography, unilateral Mammography, bilateral Screening mammography, bilateral Add-on Code (Further review) Other Diagnostic Breast Imaging MRI, breast without and/or with contrast material(s); unilateral MRI, breast without and/or with contrast material(s); bilateral 10

25 Exhibit B Program Memorandum from the Dept. of Health and Human Services 9/27/03 Subject: Coverage and Billing for Subcutaneous Image-Guided Breast Biopsy hcpro

26 Exhibit B Program Memorandum Intermediaries/Carriers Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal AB Date: SEPTEMBER 27, 2002 SUBJECT: CHANGE REQUEST 2232 Coverage and Billing for Percutaneous Image-Guided Breast Biopsy This Program Memorandum (PM) summarizes the addition of of the Coverage Issues Manual (CIM) regarding percutaneous image-guided breast biopsy. Refer to this section of the CIM for complete information regarding the policy. Background Percutaneous image-guided breast biopsy is a method of obtaining a breast biopsy through a percutaneous incision by employing image guidance systems. Image guidance systems may be either ultrasound or stereotactic. Coverage For services furnished on or after January 1, 2003, Medicare will cover percutaneous image-guided breast biopsy using stereotactic or ultrasound imaging for the following breast lesions: Nonpalpable Breast Lesions These lesions are covered for a radiographic abnormality that is nonpalpable and is graded as a Breast Imaging Reporting and Data System (BIRADS) III (probably benign), IV (suspicious abnormality) or V (abnormality). Palpable Breast Lesions Coverage also includes palpable lesions that are difficult to biopsy using palpation alone. Contractors have the discretion to decide what types of palpable lesions are difficult to biopsy using palpation. Intermediary Billing Instructions Follow the general bill review instructions in 3604 of the Medicare Intermediary manual, Part 3. The provider bills you on Form CMS-1450 (UB-92) or the electronic equivalent. Intermediary - Applicable CPT Codes 19102, percutaneous needle core, using imaging guidance 19103, percutaneous automated vacuum assisted or rotating biopsy device, using imaging guidance 10022, fine needle aspiration; with imaging guidance NOTE: For imagining guidance performed in conjunction with 19102, see codes 76095, 76096, 76360, and

27 Exhibit B Intermediary - Applicable Bill Types The applicable bill types are 12X, 13X, 14X and 85X. 2 Intermediary Applicable Revenue Codes For hospitals not subject to OPPS, the applicable revenue code is 320 (Radiology-Diagnostic) Hospitals subject to OPPS may report these services under revenue code 320 or any other appropriate revenue code. Critical Access Hospitals (CAHs), Method 1 and Method 2 (Technical), the applicable revenue code is 320. For CAHs, Methods 2 (Professional), report these services under revenue code 96X, 97X, or 98X. Intermediary Payment Requirements These CPT codes represent the technical component associated with the procedures when furnished to hospital outpatients and are paid under the OPPS. Critical Access Hospitals (CAHs) Method 1 and Method 2 (Technical)--Reasonable Cost. Method 2 (Professional)--Medicare Physician Fee Schedule (MPFS) The changes made by this PM will be made via the quarterly Outpatient Code Editor update process and the annual January update of the MPFS, respectively. Frequency In the absence of national frequency limitations, contractors can, if necessary, develop reasonable limitations. Carrier Billing Instructions Applicable CPT Codes for Percutaneous Image-Guided Breast Biopsy 19102, percutaneous needle core, using imaging guidance percutaneous automated vacuum assisted or rotating biopsy device, using imaging guidance 10022, fine needle aspiration; with imaging guidance NOTE: For imagining guidance performed in conjunction with 19102, see codes 76095, 76096, 76360, and Carrier Claims Requirements Follow the general instruction for preparing claims in 2010, Purpose of Health Insurance Claim Form CMS-1500, Medicare Carriers Manual (MCM) Part 4, Chapter 2. Claims for Percutaneous Image-Guided Breast Biopsies are to be submitted on Health Insurance Claim Form CMS-1500 or electronic equivalent. Claims should be processed in accordance with 4020, Review of Health Insurance Claim Form CMS-1500, of Part 3, Chapter IV of the MCM. 13

28 Exhibit B 3 Carrier Payment Requirements Payment and pricing information will be listed on the January update of the Medicare Physician Fee Schedule Database (MPFSDB). Pay for Percutaneous Image-Guided Breast Biopsy on the basis of the MPFS. Deductible and coinsurance apply. Claims from physicians or other practitioners where assignment was not taken are subject to the Medicare limiting charge (refer to MCM Part 3, chapter VII, 7555 for more information). Remittance Advice Notice Use appropriate existing remittance advice reason and remark codes at the line level to express the specific reason if you deny payment. If denying services furnished before January 1, 2003, use existing ANSI X claim adjustment reason code 26 "Expenses incurred prior to coverage" at the line level. Medicare Summary Notice (MSN) Messages Use the following MSN messages where appropriate: If a claim is denied because the service was performed prior to January 1, 2003, use the MSN message: "This service was not covered by Medicare at the time you received it." (MSN Message 21.11) The Spanish version of the MSN message should read: "Este servicio no estaba cubierto por Medicare cuando usted lo recibió." (MSN Message 21.11) Provider Notification Contractors should notify providers of this new national coverage on their website and in routinely scheduled training sessions. The effective date for this PM is January 1, The implementation date for this PM is January 1, These instructions should be implemented within your current operating budget. This PM may be discarded after January 1, If you have any questions, contact the appropriate regional office. Providers and other interested parties should contact the appropriate contractor. 14

29 Exhibit C HCPro, Inc., newsletter articles: Getting milked over carrier probes Digitization cometh April fools day billing rush Audits show digital coding woes E/M report: Return interpretations with breast imaging codes to referring doc, experts say hcpro

30 Exhibit C Getting milked over carrier probes Physicians can save money and put the kibosh on government s revenue cow New government guidelines gave Medicare carriers the green light in 2002 to go after providers for false claims and overpayments. Carriers used so-called probe letters to reopen claims for medical review. Sample sizes for these claims reviews have not been the petite versions from the old insurance racks; they re much broader. This means carriers could discover more mistakes, even a hint of fraud, and possibly forward your case to the Office of Inspector General. The government is encouraging providers to come forward, but [it also collects] more on refunds and penalties than it spends to go after providers, Philadelphia attorney John Knapp says of the government s overpayment recovery effort. It s a revenue cow that s paying Medicare back, but some providers, too scared to challenge official probe letters, are giving up too quickly, Knapp says. You have legal options to make sure the carriers are conducting fair reviews. Giving up and repaying your carrier for an overpayment may dramatically affect other claim reviews, so challenge sample size and check whether the carrier even has the right to reopen a claim. The following is an example of how to challenge by peppering carriers with questions during the pre- and postpayment reviews: Ask the audit s sample size. If the carrier reviewed 10 claims since January and you have 10,000, this isn t fair, Knapp says. What s the time period from which the sample was drawn? Make sure carriers take samples for periods of time after your office has updated policies. Sometimes, says Knapp, you ll find a sample period that doesn t reflect what you re doing. If the carrier limits the review to one type of service, ask why. The narrow review may be too narrow and not a fair assessment of your billing. Open and shut claims case? Carriers can reopen claims less than a year old for any reason. Fraud, or some other reasonable cause such as new evidence brought forward by a former employee, is needed to reopen claims that are one to four years old. Beyond that, the rules tighten. If the carrier tells you it s an overpayment, you may not necessarily be liable for it, says Indianapolis attorney John Murphy. The carrier must assume providers are without fault after three years from the date of the initial claim. So you fought the good fight and challenged the carrier s sample size. You think it s reasonable. But there s an overpayment: Are you responsible, or is the patient? First, expect the carrier to follow up with you on an overpayment. But don t just send a check in for $52,000, Knapp says. Provide details and analysis to limit your review and avoid additional expenses. Include the following in your overpayment note to the carrier: Your process. We discovered an overpayment through the routine operation of our compliance program. So we performed a random sample of 50 claims. 16

31 Exhibit C How you chose these claims, for what time period, providers, and tests. Why you believe there was no fraud. Circumstances behind the overpayment; include all findings relevant to your investigation. Hiding behind attorney-client privilege This is not an absolute protection against disclosure of information, Murphy says. Claim attorney-client privilege when you suspect a problem of fraud or another serious billing issue during prospective audits. But there are limits, he adds, and you ll probably have to waive this right to get favorable treatment from the government and to prove you re acting honorably. 60 days, 60 nights Your office can repay the overpayment, but you have some wiggle room since the government s timing boundaries aren t clear, Knapp says. I think the government s statutory argument is weak on this one. The government says you have 60 days within which to repay your claim when you identify an overpayment. Tip: The counting doesn t start until you do a full investigation of the overpayment and the carrier s process for reopening the claim. You must conclude this process before the clock begins. Resubmitting your claim Submit correct claims by the end of the year for the claims originally submitted in the first nine months. But for claims originally filed in the final three months of the year, you have until the end of the next calendar year to resubmit. Tip: But I d argue that if you filed your original claim on time, you have some extra time to correct it and investigate the old claim, Knapp says. It s worth a try. Just because you have to give back money does not mean it s too late to refile a claim you might be able to recoup some money. Source: Mammography Regulation Report, February 2003, published by HCPro, Inc. Digitization cometh Coding and documentation tips and traps If you want a boring old screening mammo coded, Melody Mulaik, MSHS, CPC, RCC, is not your source. But if you want some tough digitization cases coded, and answers on how to code mammos after a woman s noninvasive breast procedure, give her a call. Bring your notes and make sure they re good ones. The digital revolution is here to stay, says R. Nick Bryan, MD, PhD, president of the Radiological Society of North America. But with this explosion of technological advances, auditors are finding problems with coding and documentation in mammography and breast imaging, says Mulaik. MRR sat down with this on-the-go educator for her thoughts on how to document and code to stay in compliance. 17

32 Exhibit C Effective January 1, 2003, the revised definition of the code for the digitization of film radiographic images no longer contains mammography-type restrictions to limit its assignment. That s significant, says Mulaik, and for several reasons. The Centers for Medicare & Medicaid Services new definition of is as follows: The digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, mammography. TIP: Make sure to list this code separately in addition to the code for the primary procedure. You can now use for either diagnostic or screening exams, since the screening designation was deleted from the definition, says Mulaik. However, you must have documentation in the record to support your assignment of this add-on code. And though the corresponding order for service may support the type of mammogram, it is important that your documentation clearly indicates a screening or diagnostic exam for the primary procedure code assignment. TIP: Audits of mammography services commonly uncover a lack of documentation regarding the following two items: Number/type of views (or both) to properly distinguish screening v. diagnostic exams Nothing indicating that you performed a bilateral exam When you perform additional interpretation by utilizing digitization, make sure the documentation in the radiology report supports the assignment of this add-on code, says Mulaik. Here s a real example culled from one mammo office s notes: This examination was reviewed with the aid of Computer Aided Detection. Auditors, says Mulaik, will find this statement insufficient to comply with the further physician review requirement under this code s definition. Ideally, documentation should include an interpretation of the mammography plain films and an additional interpretation for the digitization images. To ensure that appropriate information is present in the mammography report, Mulaik s firm, Coding Strategies Inc. of Powder Springs, GA, recommends following a dictation template for mammography services. Source: Mammography Regulation Report, January 2003, published by HCPro, Inc. 18

33 Exhibit C Coding chart Radiology dictation template Name of patient and other identifier, such as hospital ID number, and patient date of birth Name of referring physician, if applicable Date and time of the examination or procedure Comparative data (prior studies viewed for comparison) Findings, results, impressions, conclusions Signature of radiologist performing interpretation and dictating report Diagnosis documentation Patient clinical history Chronic conditions, previously established diagnoses, or both Signs, symptoms, reasons for the radiology service Whether the test is a follow-up and, if so, to what condition Pertinent positive and negative findings Impression and diagnosis, if known Include the following information in the report, but do not use it for diagnosis coding: Incidental findings Statements that include verbiage such as rule out, probable, suspected, questionable, or any combination of these terms Mammography documentation Title of procedure: screening or diagnostic mammogram Based on what was ordered by the attending physician Radiologist may change screening mammogram to diagnostic as follows: - Screening mammogram ordered and performed - Documentation in radiology report defines clinical findings of screening exam, and supports decision to perform additional views (changing screening mammogram to diagnostic) - Additional documentation after diagnostic views to provide final impression Number and type of views Use of CAD and further physician review Patient symptoms or complaints for diagnostic study Source: Melody Mulaik, Coding Strategies, GA. Reprinted with permission. Mammography Regulation Report, January 2003, published by HCPro, Inc. 19

34 Exhibit C April fools day billing rush Medicare officials in Washington, DC, revised billing procedures and codes for mammography recently, according to an October 25 announcement. The updates go into effect on, of all days, April 1, But the joke s on you if you don t update your billing process to reflect the following changes: You can bill add-on code G0236 in conjunction with these four codes for primary-service diagnostic mammography: 76090, 76091, G0204, G0206. Medicare will not pay you if you bill a film and digital screening together. The same goes for film and digital diagnostic mammograms lumped together. You can bill only one screening mammogram per year: either a digital screening mammogram (G0202) or a film screening mammogram. Don t submit both on the same claim or in the same year. Watch for claims with HCPCS codes or (diagnostic mammography film) that you bill with G0204 or G0206 (diagnostic mammography digital). Your Medicare carrier will deny claims that contain a combination of these film and digital codes, such as a with a G0204. However, you can bill a screening and diagnostic mammogram together. Medicare contractors will also deny claims with an add-on code only. If you do this, contractors will send you a denial with code N122, indicating the reason for the denied bill. Add this to compliance wish list Six out of 10 mammography clinic audits are showing problems with digitization and add-on coding, according to the results of a study conducted by three large consulting firms in the East. Here are the top issues that these auditors report and how to fix them: Do not bill add-on mammography codes by themselves. Bill add-on codes with another mammography code. For example, bill add-on with or G0202. And bill add-on G0236 with 76091, G0204, or G0206. Medicare has created HCPCS code as an add-on code you can bill in conjunction with the primary service screening mammography code, 76092, or G0202. HCPCS represents digitization of film radiographic images, with computer analysis for the purpose of lesion detection, and further physician review for interpretation and screening mammography. Medicare will reject both a screening computer-aided detection (76085) and screening mammogram if you bill them together, and the screening mammogram fails the age and frequency edits in the Medicare Common Working File. Rejected: Any claims with G0236 that do not also have G0204 or G0206. Diagnosis coding tips When your physicians order a diagnostic test in the absence of signs, symptoms, or other evidence of illness or injury (i.e., screening), the principal or first-listed diagnosis is the reason for the test, according to Robert Gold, MD, vice president of clinical consulting for Alpharetta, GA based Healthcare Management Advisors. And if you 20

35 Exhibit C find something during a mammogram screening, make sure your finding isn t the first-listed diagnosis the screening code is, Gold says. Tip: The V76.1 diagnosis code series is for screening for breast malignancy. Not every one of the following codes in this series covers standard mammography: V76.10 is for unspecified V76.11 is for high-risk patients V76.12 is for other screening mammogram V76.19 is for other screening breast examination But if your patient has symptoms, list the symptoms first even when the order from the physician s office asks for a screening mammogram for breast pain. The first-listed diagnosis is the breast pain. Payment window Here are Medicare payment updates for screening and diagnostic mammograms: $81.81, par., office/facility G0202 $126.34, par., office/facility $17.74, par., office/facility $73.48, par., office/facility $90.50, par., office/facility G0204 $133.58, par., office/facility G0206 $107.87, par., office/facility G0236 $17.74, par., office/facility Source: Mammography Regulation Report, December 2002, published by HCPro, Inc. 21

36 Exhibit C Sample mammography billing audit worksheet Patient name Exam date Account number Attending MD Record/Claim comparison 1. Does the medical record a. Match the claim being reviewed? Y N b. Contain an order? Y N c. Have an ABN signed if applicable? Y N (ABN: advance beneficiary notice) Mammogram review 1. Was the patient initially treated with a screening mammogram? Y N 2. Did the order state screening? Y N 3. Did the order state diagnostic? Y N If yes, does the order state a specific identifiable problem? Y N 4. If abnormal results, did the guest return for additional exams? Y N 5 Was a stereotactic biopsy done? Y N Coding review 1. Was the bill coded per the order? Y N 2. Was the bill rejected in CareMedic? Y N 3. Was the bill denied by the carrier? Y N Source: Carol Gregory, compliance auditor at Dupont Hospital, Fort Wayne, IN. Contact her at 260/ Reprinted with permission. Source: Mammography Regulation Report, December 2002, published by HCPro, Inc. 22

37 Exhibit C Audits show digital coding woes If you are using the new digitization code as an add-on in mammography, make sure to retrain your doctors on the documentation requirements. A number of coding and reimbursement consulting firms have found mammography sites without any mention of the digitization add-on in their mammography reports. We re seeing this in a lot of audits, says Claudia Murray, a national coding consultant. Modifier 59 does not appear to be required with G0236 any more, adds reimbursement specialist Susan Granucci of Albuquerque. I just checked Medicare s October bundling table (Correct Coding Initiative) if you are billing direct digital, you are only required to use one code. If your are billing computer aided detection (CAD), two codes are required. According to preliminary information for next year s clinical procedural terminology (CPT) codes, existing code will replace G0236. The final rule on this is not yet out, however. One nationally recognized mammographer thinks that up to 100 f screenings may require CAD. But his own center offers screenings only after educating the women about extra CAD screening services. His center also tells women that extra CAD services may result in additional out-of-pocket costs. From an auditing perspective, the radiologist should mention the CAD or digitization techniques in his or her interpretative report. Failure to do so means the code is not readily supported in the medical record, Granucci says. Auditors usually look at the written report not the films or other imaging back up for evidence that you performed the service. Stay tuned for part II of this story next month, plus tips on bulk image/spot view billing. Source: Mammography Regulation Report, November 2002, published by HCPro, Inc. E/M report: Return interpretations with breast imaging codes to referring doc, experts say Billing for patient visits in imaging has been a hot topic for several years, but medical imaging professionals have greeted the adoption of visit coding with varying degrees of acceptance, according to Susan Granucci, CCS-P, a mammography and radiology reimbursement specialist from Albuquerque, NM. Medicare has different rules for new or established patients for mammography cases than it does for other cases, says Granucci. For example, you do not need to return a copy of the evaluation and management (E/M) documentation to the referring physician for new or established patients. However, for mammography patients, you must return imaging interpretations with the Breast Imaging Reporting & Database System (BIRADS) codes or language to the referring physician. And you must return a copy of the consultation report to the referring physician, in addition to imaging interpretations with BIRADS or language if the report concerns a mammography patient. 23

38 Exhibit C To report or not to report E/Ms When physician interaction with a patient is vital to accomplish a radiographic procedure, typically for invasive or interventional radiology, the visit generally involves the following: Limited pertinent historical inquiry about reasons for the examination Questions about allergies Acquisition of informed consent Discussion of follow-up Review of the medical record Do not report a separate E/M service in this setting, according to Medicare. Also, do not report an E/M code separately if the medical decision-making that evolves from your patient encounter is limited to one of the following: Whether you should perform the procedure Whether comorbidity may impact the procedure Discussion and education with the patient When to report E/M code You can report an E/M service to Medicare if you provide a significant, separately identifiable service involving the following: Taking history Performing an exam Making medical decisions distinct from the procedure Choose the appropriate E/M service code based on the type of service rendered. This satisfies the 1995 guidelines developed by the American Medical Association and Centers for Medicare & Medicaid Services. Documentation Once you determine that the E/M service is medically necessary and appropriate, follow these documentation guidelines from Granucci: 1. The E/M documentation must stand alone-separate from imaging-in order to qualify for payment, says Granucci. The medical record, she says, may consist of a legible handwritten subjective, objective assessment plan note or dictation. Document any consultation codes ( ) for the outpatient or office setting with a dictated note. 2. Visit or consultation charges are appropriate for a number of occasions, including counseling and coordination of care for face-to-face encounters for 10 or more minutes between the patient and physician. Document actual time in counseling cases in your record, Granucci says. 3. If code level is based on counseling time, 10 minutes counseling for a 15-minute visit equals code 99213; 15 minutes for a 25-minute visit equals code 99214; and 25 minutes for a 40-minute visit equals code The key: You must document time in the note when the code is based on time. 4. Regarding consultations or new patient office visits, the amount of detail and time required for these visits is almost double the requirements for an established patient. 24