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Radiology Administrator's Compliance & Reimbursement Insider, May 2005

Radiology Administrator's Compliance and Reimbursement Insider, May 1, 2005

 Inside:

CMS takes new position on PET codes: From G to CPT codes

By Jackie Miller, RHIA, CPC

The Medicare Physician Fee Schedule update issued February 11 contained an unexpected bonus for PET providers. CMS announced in Medicare Transmittal 475 (Change Request 3726) that it will begin to accept CPT codes for PET scans. The G codes that have plagued PET providers since Medicare began providing coverage of the modality are scheduled to be discontinued.

The PET G codes have been challenging to providers because they are defined in terms of a patient's condition rather than the type of exam. For example, a whole-body PET scan for initial staging of esophageal cancer is reported with code G0227, while a whole-body PET scan for initial staging of colorectal cancer is reported with code G0214. Further, G codes have a high level of granularity, requiring providers to differentiate between scans performed for purposes of diagnosis, initial staging, and restaging. This requires a depth of clinical history that referring physicians often do not provide.

The switch from G codes to CPT codes is effective for services performed on and after January 30, 2005. However, carriers will not be able to accept CPT codes until April 4 or later. (CMS originally indicated that CPT codes could be submitted starting April 4, but they notified the Society of Nuclear Medicine in mid-March that this date would likely be pushed back.) This means providers have a coding choice for services provided between January 30 and April 3: They can either hold claims and submit them with CPT codes when Medicare is ready to accept them, or they could have submitted the claims prior to April 4 using G codes. (CMS has confirmed that G codes would not be accepted after April 4.) Depending upon the type of scan performed, the professional component payment could increase significantly by billing with CPT codes rather than G codes.

The CPT codes that will be accepted by Medicare include the new (for 2005) codes for PET-CT scans. These codes must be used when CT and PET scans are performed simultaneously on the same scanner, but not when scans from separate machines are fused after the fact. Prior to 2005, there were no codes for concurrent PET-CT, and typically only the PET scan was billed, except in the rare situation when a separately ordered, medically necessary, full diagnostic CT exam was performed (see "Ask the Insider: Billing for PET/CT" in the March 2004 RACRI ). With the new PET-CT codes, however, providers can report the exact service that was performed.

All of these CPT codes will be activated in the Medicare Physician Fee Schedule. The professional component of the PET CPT codes will be paid on the basis of relative value units (RVU).

Depending on the mix of G codes that a radiology practice has reported, the new codes may represent a significant increase in reimbursement. Many G codes (e.g., code G0220, whole body imaging for diagnosis of lymphoma) carry professional component reimbursement of fewer than 2.10 RVUs, which is a lower number than the RVUs for any of the tumor-imaging CPT codes.

However, reimbursement for the technical component and global PET service will continue to be set by the carrier, leaving providers to depend on local Medicare contractors to make these determinations.

There is one last PET change included in Transmittal 475. Although the current G codes are being deactivated, CMS is instituting a new G code:

It appears this code is intended for use in billing Medicare for noncovered PET scans (i.e., to obtain a Medicare denial). However, CMS had not issued instructions for the code's use as RACRI went to press.

Facilities and radiology practices that bill for PET services may wish to take advantage of helpful information posted by the Society of Nuclear Medicine on its Web site (www.snm.org ), including a crosswalk between CPT codes and G codes.

Editor's note: To read Medicare Transmittal 475 (Change Request 3726), go to www.cms.hhs.gov/manuals/pm_trans/R475CP.pdf.

Jackie Miller, RHIA, CPC, senior consultant,Coding Strategies Inc., 5041 Dallas Hwy., Ste. 606, Powder Springs, GA 30127; 770/445-5566; jackie.miller@codingstrategies.com.

A shift toward digital mammography is often seen as step forward, a means of improving image quality, but its benefits may also work against radiologists by making them more vulnerable to lawsuits.

Digital mammography is capable of producing more accurate images than traditional film-screen mammography. It allows radiologists to manipulate images and magnify areas to gain clarity. It also, in some cases, allows for more portability of the image. Radiologists can review images at home or in other areas of the facility that have computers, so they don't necessarily have to be in the mammography area at a light box.

Digital mammography also creates more involvement for technologists in the acquisition of images. The technologist may see the initial image and choose to create a "spot" image of an area for the radiologist.

All of digital mammography's advantages-notably the newfound accuracy and efficiency-are exactly what contributes to its risk. Although radiologists have more tools at their disposal to help review images, so do the radiologists hired by defense attorneys to review images for problems.

Consider the following scenario: A plaintiff's attorney subpoenas films from a radiologist or defendant and asks another radiologist to review them. The plaintiff's attorney hopes the radiologist he or she chose as a potential expert witness will review the images and say, "I certainly would have reviewed this area further or ordered additional views." Or even better: "This is clearly a spiculated mass that is suspicious of malignancy."

The pieces of film used in this example must stand alone and speak for themselves. Technically, the film captures abnormality; the problem lies in the interpretation of what one may or may not see.

Digital images add a further dimension to this process. The issue becomes not only what someone did or didn't see, but also how they saw it. Reviewing radiologists now have additional tools at their disposal to conduct more thorough reviews of the images for potential problems with the initial radiology interpretation. Viewing consoles allow radiologists to manipulate images. Different vendors offer machines with different resolution. For example, pixel size can vary from 27 to 70 microns, but most have high-resolution views. Improved pixel size and other factors can produce exceptionally sharp images, enabling reviewers to see early microcalcifications and determine an abnormality's morphology.

Additionally, digital technology allows reviewing radiologists to manipulate and magnify images. The image can also be reviewed a second time with another set of variables (e.g., ambient light, magnification, different display screen, etc).

Although digital mammography provides a host of advantages for everyone using the technology-including both sides in a legal affair-there are also disadvantages that both sides must overcome. For example, most first-generation digital mammography users are comparing a digital image to a previous plain film image. This could raise the risk of errors.

Also, all of these enhanced features can be challenging to explain to a jury-and can create bias. For example, although digital mammography's portability is a great benefit to many radiologists, imagine the reasonable doubt that could be created just because a mammogram was read on a personal digital assistant or in a home office at 2 a.m.

Most trials that involve "failure to diagnose" claims include the testimony of a radiology expert witness explaining the finer points of mammography interpretation to a jury. The modality certainly plays a significant role in the education process. Digital images are more complex and therefore the nuances of the images may be more difficult for a jury to understand. For example, how do you recreate a digital image for a jury in the courtroom (e.g., the image may have originally been viewed using ambient lighting, etc.)?

The real question is whether using digital v. analog may hurt a radiologist's defense in practice. If using digital images is a step toward better interpretation, we must make sure that such strides are not negated by greater vulnerability.

According to the 2002 Breast Cancer Study conducted by the Physician Insurers Association of America, internists were named in 7% of the surveyed failure-to-diagnose breast cancer suits brought during the 1990s. Family physicians were named in 11% of cases and gynecologists were named in 29%. However, radiologists topped the list, being named in 40% of all failure-to-diagnose breast cancer claims. Let's hope that the next study shows that advances in technology have helped-rather than hurt-these numbers.

Cam Teems, CPC, CPHIMS, principal consultant, Practice Advantage, LLC, Atlanta. cam.teems@practiceadvantage.com.

Women receive fewer referrals for imaging procedures designed to diagnose coronary artery disease than their male counterparts, according to a consensus statement from the American Heart Association, Cardiovascular Device Liability Week reported.

Procedures such as single photon emission, computed tomography, and stress echocardiography are as effective in women as they are in men, according to the report. But diagnostic testing may need to be varied when used on female patients because of hormonal differences that may have an effect on the vascular system and test results, said Cardiovascular Device Liability Week.

"Women should not be assessed with a 'what's good for the goose is good for the gander' approach to noninvasive testing," said Jennifer H. Mieres, MD, chair of the committee that wrote the statement, according to Cardiovascular Device Liability Week.

A new study shows that it may not benefit healthy individuals to undergo full-body CT scans because the procedure's benefit does not justify the cost, the study's authors said, Aging and Elder Health Week reports. "Our findings show that the average person should think twice before having a whole-body CT examination," said study author Scott Gazelle, MD, PhD, according to Aging and Elder Health Week. "When money is wasted on ineffective interventions, it drives up the cost and decreases the availability of other necessary healthcare interventions."

The cost of a full-body scan was about $900 in 2001. The increase in life expectancy in healthy individuals was approximately six days, which is considered a minimal benefit. The study also found that 908 of every 1,000 patients have false-positive test results, which prompts further testing. "At this time, whole-body CT screening just doesn't appear to be a good use of healthcare funding," said Gazelle.

Take care when handling telephone complaints

Many patients and family members who have complaints about the service at your facility won't share their experiences until after they leave. And many people feel more comfortable sending e-mails or calling.

For those with the most serious complaints, expect a phone call during the day or week following the patient's departure. Take these complaints seriously and handle them with extreme care because patients and families in these circumstances typically leave the facility upset, mull over their experience, and then call. This means their complaints are legitimate even if you later determine that the facility staff did nothing legally or medically wrong.

It is difficult to satisfy an upset person over the phone. It requires a calm and patient tone and a helpful approach. Make sure your staff know to forward these calls directly to the patient relations line.

Here are some tips for dealing with people who call in with concerns or complaints:

Also keep the following reminders in mind-consider posting them by your phone-for the actual phone conversation:

When properly handled, the telephone can be used to defuse potentially litigious situations and help your facility improve its service. As with all complaint management, the key is to deliver on your promise and follow up with the patient when you say you will.

Editor's note: The article above is adapted from the book How to Resolve Patient Complaints to Manage Risk by Cindy Ebner, MSN, RN, Angela Burnette, JD, Christine Vogel, MPH, and Nancy Davis, MS, RHIA, published by HCPro, Inc. For more information or to purchase a copy, call customer service at 800/650-6787 or visit our Web site at www.hcmarketplace.com.

Ask 11 questions during performance reviews to assess employee compliance awareness

As you develop and implement your compliance plan, look for every opportunity to generate employee feedback and reinforce your commitment to compliance. Acting on your employees' advice and criticism can help you improve your compliance and violation-reporting programs-and show the Office of Inspector General (OIG) that you take compliance seriously. It's never a bad time to take the pulse of your organization through conversations with staff, but periodic performance reviews (PPR) provide excellent opportunities to find out what's going on.

RACRI spoke with compliance expert F. Lisa Murtha, Esq., to find out how to most effectively incorporate compliance issues into employee performance reviews. Her primary suggestion: Give the managers or supervisors who conduct these reviews a list of compliance-related questions to ask each employee.

The OIG says practices should discipline employees who violate compliance policies and procedures. You need to find out whether your employees follow your policies and procedures and whether those policies and procedures are workable.

For example, do employees have trouble understanding your policies and procedures? Do they mistakenly believe those policies and procedures are unimportant?

"You need to find out as soon as possible if employees are failing to use your compliance resources or not promptly reporting compliance violations," says Murtha. And if your employees don't buy into your program, take immediate action to correct the situation.

Employee PPRs are the most direct route to obtain answers about your compliance program. "You can get some of your most valuable compliance feedback when you sit down face-to-face with employees and discuss their compliance concerns," she says. If you go into each review with a predetermined set of compliance questions, you're more likely to get consistent feedback.

To obtain consistent, usable employee feedback about compliance issues during PPRs, ask the right questions. Draft a list of questions and distribute it in a memo to all employees who conduct performance reviews, suggests Murtha.  A memo will instruct reviewers on how to incorporate the compliance questions into the group of questions they ask during the review. It will provide guidelines that tell reviewers to write down employees' answers and send them to the compliance office for review and further action, if necessary.

Determine whether your employees are fully aware of your compliance resources and what they think about your policies and procedures.

If employees don't know as much as they should about your policies and procedures, or if they think the policies and procedures are too difficult to use, find out why your compliance message isn't getting across and ask them for specific information about how you can improve your policies and procedures. Sample questions include the following:

1. Do you keep a copy of our code of conduct and our compliance policies handy? If your employees don't have compliance materials readily available at their work sites, correct this immediately.

2. Have you ever consulted our code of conduct or our compliance policies when dealing with a question? Find out whether your employees actually use your compliance resources in their work. "The best compliance program in the world isn't worth anything if your employees won't use it," says Murtha.

If they've used your policies and procedures in day-to-day operations, find out how they did so. If they don't consult your policies and procedures when faced with questions, find out why.

3. Are our compliance policies easy to understand? Ask employees whether they're able to easily understand your compliance policies and procedures. If employees think your policies and procedures are complicated, consider revising them to make them easier to follow-thus making employees more likely to follow them. To help your compliance program reevaluation, determine which specific policies and procedures employees find confusing and why.

4. Are our compliance policies easy to follow in the context of your job, or do they complicate your routine? One complaint that compliance officers sometimes hear is that policies and procedures are too difficult to follow or that they unduly complicate an employee's routine.

"If an employee says he has trouble following certain procedures, ask him to identify specific instances and give you a detailed account of how they were difficult to follow and how the employee dealt with the problem," Murtha says. This input can help you reevaluate and perhaps rewrite complex procedures.

Note: Take the same approach for policies and procedures that employees find easy to follow but unrealistic in daily operations. If your policies and procedures unnecessarily complicate your employees' routine, they're less likely to follow them. Ask employees to identify which policies are unrealistic and how they think those policies could be improved. You may obtain some valuable employee feedback that can help you redesign the policy for easier use.

5. Do you think our compliance training is adequate? Employees sometimes feel that they haven't been adequately trained to handle compliance issues or use your compliance materials. Ask them whether they need more training or if your training program needs to be revised. Because employees face real-life compliance issues every day, their input can help you build an education program that meets their needs.

6. Can you think of any additional compliance issues our policies and procedures should address? Give employees a chance to comment on your policies and procedures. If you ask for suggestions about additional topics to address, the opportunity should encourage employees to share their thoughts about any aspect of your compliance program that they find useful or problematic. Once employees answer a few compliance-related questions, they will be more likely to think of additional issues.

Questions asked during the PPR are also useful in determining whether your compliance violation-reporting system works. Ask employees the following questions to measure their comfort level with the system and to see whether your practice inadvertently discourages complete reporting:

7. Are you aware of the systems we have to report compliance problems (e.g., hotlines, e-mail, etc.)? Find out whether employees know about your violation-reporting system and how it works. If they don't, reeducate them. Hold staff meetings or issue written instructions to employees describing in detail the system and how to use it.

8. If you discovered a compliance violation, would you feel comfortable using our system to report the violation? How do your employees generally feel about the system? Are they confident in the system and their ability to access it easily and quickly? If they're reluctant to report violations because they don't trust the system, take steps to create a more supportive atmosphere for reporting violations. And if their reluctance stems from finding the system too difficult to use, you may need to make corrections in your system.

9. Have you ever felt discouraged from reporting a compliance violation? This is a critical question. The best violation-reporting system won't help you if your employees don't use it, even if they know how. Find out whether they're afraid to use the system and why. Take action to change their perceptions.

For example, employees might think that their chances of job advancement will be jeopardized if they report violations or that reporting will make them look bad in the eyes of their superiors. To counter this fear, reeducate employees and remind them that compliance is a priority in your practice and that commitment to compliance actually promotes employees' chances for advancement.

10. Do you think you'll get in trouble for reporting a compliance violation? Employees sometimes fear that a violation report won't be kept confidential and that they'll get in trouble-often with their coworkers-if they report violations.

If that's the case, emphasize that their privacy will be protected as much as is legally possible and that reporting compliance violations is part of their job. If they're confident that you'll take all possible steps to protect their confidentiality, they'll have much more confidence in the system.

11. How do you think we can improve our violation reporting system? Give employees a chance to comment on your violation-reporting system. They may think of something during the PPR that will help you fine-tune the system.

F. Lisa Murtha, Esq., partner in the consulting firm of Parente Randolph, LLC, in Philadelphia.

Model memo

Here's a memo drafted with the help of compliance expert F. Lisa Murtha, Esq. It lists compliance questions that your reviewers can ask in addition to any questions they normally ask during employee performance reviews. The responses can help you evaluate how well your employees follow your compliance policies and procedures and whether you foster an environment that supports compliance activities and violation reporting.

Give this memo to everyone who conducts performance reviews. Tell them to forward the employees' answers to your compliance officer so he or she can evaluate the results and plan follow-up action.

To: Employees conducting staff performance reviews

From: Compliance officer

Date: May 1, 2005

Re: Compliance questions during staff evaluations

In our continuing effort to improve compliance efforts, ask the following questions during all employee performance evaluations. Forward employees' answers to me. I will use them to plan any necessary follow up or further action.

To keep employees from interpreting these questions as accusations of wrongdoing, assure them before asking the questions that they aren't in any trouble. Explain that you're asking the questions to get the employee's honest opinion of our compliance program and views about how to improve it.

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