Diagnostic Radiology

Transcription

1 Diagnostic Radiology Caren Swartz, CPC-I, CPC-H, CPMA, CIC Overview Terminology Associated with Diagnostic Radiology Proper Reporting CPT Challenges CMS Issues 1

2 Have fun! Diagnostic Radiology What is Diagnostic Radiology? An area of medicine that uses different imaging techniques (e.g., X-rays, MRI and CT scans) to investigate the possible causes of a person's symptoms, or disease. 2

3 Diagnostic Radiology This differs from therapeutic which would aide in the treatment of disease such as cancer using radiation oncology. There can also be, at times, some confusion i.e. mammograms. Diagnostic vs. Screening. The screening is for the asymptomatic patient to screen for potential disease while the diagnostic mammograms are searching out known disease or metastasis. Modalities of Diagnostic Radiology Plain Films MRI CT Ultrasound Mammography these are the classics but what about 3

4 Diagnostic Radiology Interventional Procedures - angiography Non-invasive Vascular studies duplex (Medicine Section) Cardiac Caths (Medicine Section) All would be forms of Diagnostic Radiology regardless whether a radiologist is doing the study or not How Did They Do That? What Does It Look Like? 4

5 MRA Carotid 5

6 Coil for embolization, pretty cool right!! Coiling for brain aneurysm 6

7 4D ultrasound Mammogram showing mass 7

8 Before the Code is Selected Consider these other issues Is there an Order? Is there Medical Necessity? Is the Report complete? The Order Medicare Claims Processing Manual, Chapter 23 You need a written, signed document from the treating physician/practitioner, which is hand delivered, mailed or faxed. A Atelephone call llby treating ti physician/practitioner or office to the testing facility. An by treating practitioner or staff. 8

9 Medical Necessity Appropriate ICD-9-CM CM that supports medical necessity Must reflect a sign, symptom, condition or injury Screening services will need appropriate V-code. Communicate with your providers for rule out Understand LCD but do NOT code for payment from them. I think this would be easy for medical necessity. 9

10 ICD-10 Impact Will ICD-10 cause more claim issues? Will contracts need to be renegotiated to include more specific codes? Will payments be paid based on diagnosis? dag oss Will your work output slow down as you go through the learning curve and is your practice ready? Lets compare ICD (spontaneous pneumothorax) 824.0(fracture,closed, medial malleolus) 793.6(abnormal finding radiology exam abdomen) V10.3(History of breast cancer) ICD-10 J93.0(spontaneous pneumothorax) S82.56xA (initial episode of care, unspec side) R93.5 (abn finding, radiology exam, abd.) Z85.3 (History of breast cancer) 10

11 American College of Radiology Search engine provides all sorts of documentation guidelines, current issues in Radiology as well as coding information Documentation What is required? What are the elements of the report? Who is responsible for the report? How does the EHR impact this? What are the legalities? 11

12 The Report YOU as the coder can help to educate your physicians by maintaining a good rapport with him/her and discussing documentation issues and rules. Lets review what the ACR outlines as appropriate format for this Report Format Clear and Concise Report Provides high quality communication The report should stand independent of the interpreting radiologist The quality of the report should not vary as a result of there being different interpreting radiologists 12

13 The Report Failure to communicate results clearly and effectively is one of the top three reasons for litigation/malpractice against Radiologists. Clear communication, understanding who the intended reader of the report will be can keep the physician away from legal pitfalls. The Report - Title The Title Some institutions standardized Provided to transcriptionist with the request Be sure the title that is on the order is the desired title of the report Clarification at time of dictation of actual title or study performed 13

14 The Report - Indications Documentation of actual reason for the study Many standard studies do not necessarily require this with the written report Determines the appropriateness of study Many third party payers and Medicare now require an indication before they will reimburse. The Report - Indications How about you as the coder? How many times have you had no indication for a study and the study is read as normal?? What do you do? How do you code that? Query the Physician? 14

15 The Report - Indications The indication should be a simple, concise statement of the reason for the study and/or applicable clinical information or diagnosis. The indication may also be implied for example a chest X-ray requested for cough and fever implies the question Does this study indicate the presence of pneumonia? The Report Procedure Every radiologic exam has a procedure associated with performing the exam Most routine studies the procedure is implied by the title PA & LAT Chest and in this case a separate procedure section is not necessary. 15

16 The Report - Procedure However a separate procedure section may be a convenient place to document consent, technical limitations, drugs and isotopes or contrast material associated with the study. Interventional procedures should have an entire procedure/operative report dictated indicating all aspects of the procedure. The Report - Findings A description of the results of the study, relevant information from any previous studies, pertinent clinical findings and reasoning supporting radiologists conclusions. The Findings section should support the impression. 16

17 The Report - Impression A list of summary statements Includes both conclusions and recommendations for further evaluation and management Interesting ees Note..In oe asu survey >50% 50%of referring physicians read only the impression section of the report. The Report - Conclusion Since increasingly more often the patient is the reader of the report, it is even more important to keep the report clear and concise. Should be understandable. Failure to clearly communicate can result in lawsuits. 17

18 Ownership Ownership of the written report is held by the organization providing the radiologic service. Maintenance and security of the original record also falls with the organization or individual who performed the exam. Since 1996 HIPAA, ALL patients have a legal right to a copy of their report. Coding Challenges Reports hard coded from Non-coders Modifier and component coding assignment from chargemasters for procedures such as interventional radiology. Coders and Support staff need to coordinate soft and hard coding of procedures. 18

19 How do we Code? Document must state views or number of views taken (not number of films) We must understand modifiers such as -26 and TC We need to have laterality a documented ed (wait for ICD-10!) Understand if this is a repeat procedure CPT Issues Guides for Radiology S&I Bundled Items Contrast Modifiers Component Coding 19

20 Supervision and Interpretation Radiologic portion of a procedure is considered radiologic supervision and interpretation This is understood while performing Interventional procedures where there are catheters being advanced (surgical code), then, x-rays performed, S&I NOT synonymous with -26 modifier. Supervision and Interpretation In the instance where there might be (although rarely in my experience) two physicians sharing this code, perhaps a cardiologists does the S and the radiologist does the I, both should append a -52 modifier indicating i a reduced d service. 20

21 S & I - ER Patients A patient presents to the ER and has a diagnostic radiologic procedure done. The ER physician interprets and treats the patient. The Radiologist og reads the x-ray also Who gets paid for the PC? S & I - ER Patients The claim will be paid by the entity who gets there claim in first. Insurance companies make no effort to develop the claim to assign payment. In certain instances both the ER Physician and Radiologist can be paid with -77 modifier if the initial reader has questions/or believes better expertise is required. 21

22 Contrast Contrast lights up a structure The phrase with contrast needs to be administered in one of the following ways: Intravascularly into a vein Intra-articularly in a joint Intrathecally t th within the spinal fluid According to CPT contrast administered orally or per rectum alone does not represent a study with contrast Contrast Some codes are broken out by: Without contrast With contrast Without followed by with contrast Watch for coding parentheticals to aid in additional coding opportunities. Be sure to bill the HCPCS code for contrast material used. 22

23 Contrast Payments for LOCM is the average sales price (ASP) plus 6%, in accordance with the standard methodology for drug pricing. CPT & HCPCS Modifiers -26 -Professional component used for interpretation of a procedure TC -Technical component used for the owners/technician running equipment -59 distinct procedural service, may be used to indicate a service was carried out independently of another -50 bilateral when appropriate (ICD-10 may change this) 23

24 CPT & HCPCS Modifiers -52 reduced services, when the CPT description is not completely carried out, i.e. when the code says minimum of 2 views and you only do one. -76 repeat by same MD -77 repeat by another MD Think chest x-ray being repeated for pneumothorax Component Coding Vascular procedures Include selective catheterization code (surgery section, i.e , 46,47) The radiology code that would correspond to that area catheterized (75710, angiography, extremity, unilateral, radiological supervision and interpretation) 24

25 Transcatheter Procedures Usually include supervision and interpretation. Watch parentheticals. Pay attention to surgical codes that may need to be billed along side. Diagnostic Ultrasound Divided by anatomy Codes can be: Limited exam of a specific organ/quadrant. Less then is needed for a complete study. Complete watch the code for complete description of what needs to be documented for a complete study. 25

26 Diagnostic Ultrasound Requires a permanent record Recorded images with measurements Final written report should be issued for inclusion in the medical record. Ultrasonic guidance procedures also require permanently recorded images of site localized, as well as description of procedure. Obstetrical Ultrasound Codes include determination of number of gestational sacs and fetuses Sac/fetal measurements appropriate for gestation Amniotic fluid volume/gestational sac shape Maternal uterus and adnexa Intracranial/spinal/abdominal anatomy 4 chambered heart, umbilical cord insertion site Placental location 26

27 Radiologic Guidance Procedures Know the method; ultrasound, fluoro, CT, MRI (watch Fluoro codes, many are included in the surgical procedure codes) Know reason you are using these codes; needle placement, catheter placement, injection procedure, intra-operative guidance Is the code an add-on Other Procedures Fluoroscopy(separate procedure) by time(76000) Exams for kids nose to rectum for foreign body(76010) Exam for abscess, fistula or sinus (76080) Exam of surgical specimen (76098) Don t forget your unlisted codes 27

28 What Does NOT Get Billed Scout films a film used prior to actual study/alignment Spot films Operative arteriogram Portable hand held devices unless they can produce/store a permanent picture/report EHR/EMR Watch systems that claim to code Understand what your system can offer Understand and Discuss with providers the pitfalls of these systems An electronic system cannot provide medical decision making! 28

29 CMS Forms MPPR PATH CMS The ABN Form (CMS-R-131) The ABN must be issued when the health care provider believes that Medicare may not pay for an item or service that Medicare usually covers because it is not considered medically reasonable and necessary for this patient in this particular instance. See Medicare Claims Processing Manual Chapter

30 CMS The ABN Form (CMS-R-131) The ABN also serves as an optional notice that providers/suppliers may use to forewarn beneficiaries of their financial liability prior to providing care that Medicare never covers. ABN issuance is not required in order to bill a beneficiary i for an item or service that is not a Medicare benefit and thus, never covered. ABN MODIFIERS The following are claims modifiers associated with ABN use. Please refer to the Medicare Claims Processing Manual,Publication , Chapter 1, Section 60 for more specific instructions on filing claims associated with ABNs. The manual can be found at IOM/list.asp on the CMS website. GA Waiver of Liability Statement Issued as Required by Payer Policy This modifier is used to report a required ABN was issued for a service and is on file. A copy of the ABN does not have to be submitted but must be made available upon request. GX Notice of Liability Issued, Voluntary Under Payer Policy This modifier is used to report a voluntary ABN was issued for a service. GY Notice of Liability Not Issued, Not Required Under Payer Policy This modifier is used to report that an ABN was not issued because the item or service is statutorily excluded or does not meet the definition of any Medicare benefit. GZ Item or Service Expected to Be Denied as Not Reasonable and Necessary This modifier is used to report an ABN was not issued for a service. 30

31 CMS ABN Form The provider must enter in field E (Reason Medicare May Not Pay) the reason why the service may not be covered. Three examples are: 1. Medicare does not pay for this test for your condition. 2. Medicare does not pay for this test as often as this (denied as too frequent). 3. Medicare does not pay for experimental or research use tests. CMS ABN Form Reason #1 is appropriate for a patient whose diagnosis is not covered under the Medicare LCD for the exam. Reason #2 is appropriate for a service with frequency limitations, like a screening mammogram. 31

32 ABN The ABN gives the patient three choices: Option 1: The patient wants to receive the service and also wants the service to be submitted to Medicare. The provider may collect payment from the patient at the time of service, but if Medicare decides to pay, the patient s payment must be refunded. Option 2: The patient wants to receive the service but does not want it to be submitted to Medicare. The provider is not required to submit a claim when this option is selected. Option 3: The patient does not want the service. These are the only three choices. The patient cannot choose to have the service but not pay for it. ABN The patient or representative must choose one of the three options listed on the ABN. The provider may never choose an option for the patient. It is a serious compliance violation to ask a patient to sign an ABN with a choice already checked. The ABN can be signed by the Medicare beneficiary or his representative. CMS defines a representative as an individual who may make health care and financial decisions on a beneficiary s behalf. Examples include a person who holds a durable medical power of attorney for the patient, or the patient s guardian. 32

33 MPPR - What Does CMS Have to Say MPPR Effective 1/2011 Medicare mandated a multiple procedural payment reduction from 25% to 50% for CT, CTA, MRI, MRA and Ultrasound. When two or more codes are performed on the same patient by the same physician during a single session, the TC for the second and subsequent imaging will be reduced by 50%. Medicare MPPR In the 2012 Medicare proposed rule, it was proposed to attach the PC to the reduction, the ACR told CMS that this proposal is scientifically unfounded, based on flawed assumptions, and may limit patients ability to receive efficient i care. 33

34 MPPR This would impact reimbursement tremendously for interpretation and diagnosis. We will all await Medicare s decision on this, you can view the letter from the ACR on their website PATH Definitions PATH Physician At Teaching Hospital Resident an individual who participates in an approved GME program OR a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting. GME Graduate Medical Education Program Teaching Physician A physician (other than a resident) who involves residents in the care of his or her patients 34

35 PATH Definitions Direct Medical/Surgical Services services to individual patients that are either personally furnished by a physician or furnished by a resident under the supervision of a physician in a teaching hospital making the reasonable cost election for physician services furnished in teaching hospitals. All payments are made by the FI for the hospital. PATH Payments Services furnished in teaching settings are paid under MPFS if services are: Personally furnished by physician who is not a resident Furnished by a resident when a teaching physician is physically present during the critical or key portions of the service; or Furnished by residents under a primary care exception within an approved GME 35

36 PATH Documentation Guidelines Both Residents and Physicians may document physician services in the medical record. Document must be dated Contain C i a legible signature or identityi ALL items may be dictated or transcribed Typed; hand-written; OR computer generated PATH EHR and Macros (command in a computer or dictation application) May use in a secured system. Must provide customized information sufficient to support medical necessity determination. ti Must sufficiently describe the specific services furnished to the patient for that specific date. IF macro is the only thing documented this is NOT considered sufficient. 36

37 Students PATH An individual who participates in an accredited educational program (e.g., medical school) that is not an approved GME and is not considered an intern or resident. MEDICARE does NOT pay for ANY services furnished by a student. t Surgery - PATH The teaching surgeon is responsible for the preoperative, operative, and post-operative care of the beneficiary. The teaching physician s presence is not required during the opening and closing of the surgical field unless these activities are considered to be critical or key portions of the procedure. 37

38 PATH During non-critical or non-key portions of the surgery, if the teaching surgeon is not physically present, he or she must be immediately available to return to the procedure, i.e., he or she cannot be performing another procedure. PATH Interpretation of Diagnostic Radiology and Other Diagnostic Tests.-Medicare pays for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by or reviewed with iha teaching physician. i 38

39 PATH -Documentation If the teaching physician s s signature is the only signature on the interpretation, Medicare assumes that he or she is indicating that he or she personally performed the interpretation. If a resident prepares and signs the interpretation, the teaching physician must indicate that he or she has personally reviewed the image and the resident s interpretation and either agrees with it or edits the findings. Medicare does not pay for an interpretation if the teaching physician only countersigns the resident s interpretation. PATH Acceptable Documentation I certify that I have directed and participated in the documented procedure, reviewed the images and agree with the interpretation. Dr. Attending 39

40 Thank You! Questions???? Caren J Swartz, CPC, CPC-H, CPMA, CPC-I Caren@practiceintegrity.com