Embed Size (px)
Citation preview
1
Diagnostic Radiology
Caren Swartz CPC-I CPC-HCaren Swartz, CPC-I, CPC-H, CPMA, CIC
Overview
Terminology Associated with Diagnostic Terminology Associated with Diagnostic Radiology
Proper Reporting
CPT Challenges
CMS Issues CMS Issues
2
Have fun!
Diagnostic Radiology
What is 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.
3
Diagnostic Radiology
This differs from therapeutic which wouldThis 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 theScreening. 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 Plain Films
MRI
CT
Ultrasound
Mammography these are the classics but Mammography…these are the classics but what about…
4
Diagnostic Radiology
Interventional Procedures angiography Interventional Procedures - angiography
Non-invasive Vascular studies – duplex (Medicine Section)
Cardiac Caths – (Medicine Section)
All would be forms of DiagnosticAll 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?
5
MRA Carotid
6
Coil for embolization, pretty cool right!!
Coiling for brain aneurysm
7
4D ultrasound
Mammogram showing mass
8
Before the Code is Selected…
Consider these other issues… Is there an Order?
Is there Medical Necessity?
I th R t l t ? Is the Report complete?
The Order
Medicare Claims Processing Manual Medicare Claims Processing Manual, Chapter 23You need a written, signed document from the
treating physician/practitioner, which is hand delivered, mailed or faxed.
A t l h ll b t tiA telephone call by treating physician/practitioner or office to the testing facility.
An email by treating practitioner or staff.
9
Medical Necessity
Appropriate ICD-9-CM that supports medical Appropriate ICD 9 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”y p Understand LCD but do NOT code for payment
from them.
I think this would be easy for medical necessity….
10
ICD-10 Impact
Will ICD 10 cause more claim issues? 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?d ag os s
Will your work output slow down as you go through the learning curve and is your practice ready?
Lets compareICD-9 ICD-10
512 8(spontaneous J93 0(spontaneous 512.8(spontaneous pneumothorax)
824.0(fracture,closed, medial malleolus)
793.6(abnormal finding radiology
J93.0(spontaneous pneumothorax)
S82.56xA (initial episode of care, unspec side)
R93 5 (abn findingfinding radiology exam abdomen)
V10.3(History of breast cancer)
R93.5 (abn finding, radiology exam, abd.)
Z85.3 (History of breast cancer)
11
American College of Radiology
www ACR comwww.ACR.com
Search engine provides all sorts of documentation guidelines, current issues in Radiology as well as coding information
Documentation
What is required? 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? What are the legalities?
12
The Report
YOU as the coder can help to educate 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 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 The quality of the report should not vary as a result of there being different interpreting radiologists
13
The Report
Failure to communicate results clearly andFailure 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 The TitleSome 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
14
The Report - Indications
Documentation of actual reason for the study 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 i i di ti b f th ill i brequire an indication before they will reimburse.
The Report - Indications
How about you as the coder? 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?y
Query the Physician?
15
The Report - Indications
The indication should be a simple concise 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 indicateimplies the question Does this study indicate the presence of pneumonia?”
The Report – Procedure
Every radiologic exam has a 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.
16
The Report - Procedure
However a separate procedure section 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 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 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.”
17
The Report - Impression
A list of summary statements A list of summary statements
Includes both conclusions and recommendations for further evaluation and management
Interesting Note..In a survey >50% of e es g o e a su ey 50% oreferring physicians read only the “impression” section of the report.
The Report - Conclusion
Since increasingly more often the patient 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.
18
Ownership
Ownership of the written report is held by 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 examindividual 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 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 Coders and Support staff need to coordinate “soft” and “hard” coding of procedures.
19
How do we Code?
Document must state views or number of 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 documented e eed o a e a e a y docu e ed(wait for ICD-10!)
Understand if this is a repeat procedure
CPT Issues
Guides for Radiology Guides for RadiologyS&I
Bundled Items
Contrast
Modifiers
Component Coding
20
Supervision and Interpretation
Radiologic portion of a procedure is 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 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
d 2 difi i di i d dappend a -52 modifier indicating a reduced service.
21
S & I - ER Patients
A patient presents to the ER and has a A patient presents to the ER and has a diagnostic radiologic procedure done.
The ER physician interprets and treats the patient.
The Radiologist reads the x-ray alsoe ad o og s eads e ay a so
Who gets paid for the PC?
S & I - ER Patients
The claim will be paid by the entity who gets 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 theRadiologist can be paid with -77 modifier if the initial reader has questions/or believes better expertise is required.
22
Contrast
Contrast “lights up” a structure 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 I t th ll ithi th i l fl id Intrathecally – within the spinal fluidAccording to CPT contrast administered “orally
or per rectum alone” does not represent a study “with contrast”
Contrast
Some codes are broken out by: 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.
23
Contrast
Payments for LOCM is the average sales 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 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 outused to indicate a service was carried out independently of another
-50 – bilateral when appropriate (ICD-10 may change this)
24
CPT & HCPCS Modifiers
52 reduced services when the CPT -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 MDThink chest x-ray being repeated for
pneumothorax
Component Coding
Vascular procedures Vascular procedures Include selective catheterization code
(surgery section, i.e. 36245, 46,47)
The radiology code that would correspond to that area catheterized (75710, angiography, extremity unilateral radiological supervisionextremity, unilateral, radiological supervision and interpretation)
25
Transcatheter Procedures
Usually include supervision and Usually include supervision and interpretation.
Watch parentheticals.
Pay attention to surgical codes that may need to be billed along side.eed o be b ed a o g s de
Diagnostic Ultrasound
Divided by anatomy 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.
26
Diagnostic Ultrasound
Requires a permanent record Requires a permanent record
Recorded images with measurements
Final written report should be issued for inclusion in the medical record.
Ultrasonic guidance procedures also 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 Codes include determination of number of gestational sacs and fetuses
Sac/fetal measurements appropriate for gestation
Amniotic fluid volume/gestational sac shape
M t l t d d Maternal uterus and adnexa
Intracranial/spinal/abdominal anatomy
4 chambered heart, umbilical cord insertion site
Placental location
27
Radiologic Guidance Procedures
Know the method; ultrasound fluoro CT 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 Fluoroscopy(separate procedure) by time(76000)
Exams for kids nose to rectum for foreign body(76010)
Exam for abscess, fistula or sinus (76080)a o abscess, s u a o s us ( 6080)
Exam of surgical specimen (76098)
Don’t forget your unlisted codes
28
What Does NOT Get Billed
Scout films a film used prior to actual Scout films – a film used prior to actual study/alignment
Spot films
Operative arteriogram
Portable hand held devices – unless they Portable hand held devices – unless they can produce/store a permanent picture/report
EHR/EMR
Watch systems that claim to code 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 An electronic system cannot provide medical decision making!
29
CMS Forms 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 thisreasonable and necessary for this patient in this particular instance. See Medicare Claims Processing Manual Chapter 30.
30
CMS The ABN Form (CMS-R-131)
The ABN also serves as an optional noticeThe 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
i d i d bill b fi inot required in order to bill a beneficiary 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 100-04, Chapter 1, Section 60 for more specific instructions on filing claims associated with ABNs. The manual can be found atassociated with ABNs. The manual can be found at http://www.cms.gov/Manuals/ 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 N i f Li bili N I d N R i d U d P P li 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.
31
CMS ABN Form
The provider must enter in field E (Reason Medicare p (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 p y presearch use tests.
CMS ABN Form
Reason #1 is appropriate for a patient 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.
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• 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 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 “anhis 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.
33
MPPR - What Does CMS Have to Say… MPPR – Effective 1/2011 Medicare mandated a 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 andsingle session, the TC for the second and subsequent imaging will be reduced by 50%.
Medicare
MPPR In the 2012 Medicare proposed 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
i bili i ffi ipatients ability to receive efficient care.
34
MPPR
This would impact reimbursement 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 www.ACR.com
PATH Definitions
PATH – Physician At Teaching HospitalPATH 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
35
PATH Definitions
Direct Medical/Surgical Services 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 h i l ki h blhospital 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 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
36
PATH
Documentation Guidelines Documentation GuidelinesBoth Residents and Physicians may
document physician services in the medical record.
Document must be dated
C i l ibl i id iContain a legible signature or identityALL items may be dictated or transcribed
Typed; hand-written; OR computer generated
PATH
EHR and Macros (command in a computer 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 d t i tidetermination.
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.
37
PATHStudents
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
f ANY i f i h d b t d tpay for ANY services furnished by a student.
PATH
Surgery Surgery -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 therequired during the opening and closing of the surgical field unless these activities are considered to be critical or key portions of the procedure.
38
PATH
During non critical or non key portions of 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
f i h dperforming another procedure.
PATH
Interpretation of Diagnostic Radiology and 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
i h hi h i iwith a teaching physician.
39
PATH -Documentation
If the teaching physician’s signature is the only If the teaching physician 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 theshe 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
