Radiology Administrator's Compliance & Reimbursement Insider, November 2005

Once you decide to use an RFP, include several pieces of information in the documents to receive the best proposals possible.

"Traditionally, radiology has had an adversarial relationship with vendors," said Kroken. "We don't want to tell them anything, but we want them to give us exactly what we need."

If you provide vague information about the needs or your practice, it will lead to vague price quotes and information about the system or service you are purchasing. For this reason, an accurate practice profile is a key component of your RFP. Kroken recommended including the following information in your profile:

1. The size of your practice. Often, pricing is based on the number of physicians in a practice, said Kroken.

2. Your facility's sites of service and types. For example, are they hospital-based? How many of them have downloads? Make sure that whom ever you deal with has worked with organizations of similar sizes and types.

"A system can have a lot of user-friendly functionality, but if [the company hasn't] dealt with hospital downloads and the volume and issues associated with it, [it] can be overwhelmed," said Kroken.

3. Future growth expectations. Providing information about potential future growth is key, because whatever system or service you decide on has to be able to accommodate that growth.

Kroken suggests that you focus on growth trends from the past few years to make predictions about the future. Will you continue to grow at the same rate? Or will market factors make you grow faster or slower than in the past? Getting a grip on this information can help you to negotiate solid deals that will allow you to add on to the system in the future.

4. Managed care profile. Some systems will verify payment amounts to ensure that your organization isn't being shortchanged. Providing information about your payers can help vendors determine your needs.

5. Information about employees/system users. Include information about employees, such as how many there are and whether they work on- or off-site.

6. Details about other systems that you will need to integrate. For example, if you have a solid system for mammography reporting that you don't want to replace, you'll have to find out whether it is compatible with whatever new system you want to install.

7. Data storage requirements. Outline your current storage needs and anticipate what you might need in the future. Also look at issues related to how data is backed up and how it would be recovered if lost.

In addition to providing information about your own facility, request information about the vendor. Kroken said that knowing the following information can give you a good snapshot of a vendor or service provider's qualifications:

Establishing selection criteria for your RFP will help your organization avoid being swayed by a smooth-talking salesperson, said Kroken. It gives you a concrete wish list that you can use to make objective comparisons.

The first step in developing these criteria is to focus on your needs versus your wants.

Ask these key questions:

chase or service? To determine this, Kroken draws a

work flow diagram and looks for areas of process

duplication.

organization?

Some examples of "must have" items you may want on your wish list include the following:

system

companies

When it comes to these "must have" items, ask detailed questions. For example, if you are looking for a billing service, you might want it to use radiology-certified coders. Kroken said she encountered one billing firm that said it had all radiology-certified coders, but further questioning revealed that the coders weren't certified through an external organization, rather internally thorough their own process. "These are the kinds of details you want to have," she said.

After setting your selection criteria, develop a submission packet for the vendors. This should include a cover letter along with the following information:

Once the responses come in, compare them and eliminate the unqualified candidates. Then schedule demonstrations with the finalists.

At this stage, include the people who will use the new equipment or service in the decision-making process, said Kroken. Those people should test the equipment for usability and have input into the final purchasing decision.

Kroken gives an evaluation form to staff who test new products and asks them for a final recommendation on what to buy. Ultimately, the facility may go with a different option for cost reasons but either way, the input is critical.

Site visits are also a good idea. Don't let the vendor or service provider take you to a site that performs well but isn't similar to your organization. Ask to see a site that looks like your own.

Insider source

Patricia Kroken, FACMPE, CRA, Healthcare Resource Providers, LLC, Albuquerque, NM.

The results of the highly anticipated Digital Mammographic Imaging Screening Trial (DMIST) are in, and digital mammography outperformed film in detecting cancers in women under age 50 and women with dense breasts.

However, it wasn't all good news for digital equipment. "[Looking at the study population as a whole] there was no significant difference between digital and film," says Etta Pisano, MD, principal investigator for the trial. This means that for the majority of women in the screening age group, there is no particular advantage to receiving a digital mammogram.

However, researchers encouraged women under the age of 50 and women with dense breasts to seek out digital mammograms, and the mainstream press widely publicized that message. This may put more pressure on your facility to purchase digital equipment if it hasn't already.

Many facilities have considered going digital but were waiting for some hard data before making the leap. This trial may give them the validation they need to make the purchase, says Pisano.

The American College of Radiology Imaging Network conducted the study, which was designed to compare the performance of digital to film mammography. Nearly 50,000 women participated in the trial and, as part of the protocol, underwent two screening mammograms-one digital and one film.

Breast cancer was confirmed by either a biopsy within 15 months after the subject entered the trial or by a follow-up mammogram at least 10 months after study entry, according to the authors.

The trial began in 2001 and manufacturers updated digital equipment throughout the course of the trial to ensure that the most state-of-the-art equipment was used, says Pisano.

Although digital imaging provided superior cancer detection only to certain groups of patients (which included perimenopausal and premenopausal women), the researchers noted that the technology had other more universal advantages, such as

"In a digital image, the x-ray transmission can be manipulated to enhance visualization of subtle structural changes in tissue over the entire breast," the authors wrote in the study. "For mammograms, the most problematic areas are those in which cancers can be hidden by adjacent dense tissue owing to small differences in contrast between lesions and the fibroglandular background. The visibility of a subtle mass or cluster of calcifications present in the image can be increased if the image contrast is adjusted."

Although digital technology can detect some cancers that film misses, neither modality is able to detect all breast cancers. Therefore, it is also critical to evaluate any palpable finding detected after a negative screening mammogram, study authors wrote.

However, despite the advantages of digital equipment, one main drawback exists-the cost. Digital systems typically cost about $500,000. This is one-and-a-half to four times the cost of a film system, according to the study. (Pisano says the study authors plan to complete a cost-effectiveness analysis of digital mammography soon.)

Although reimbursement is also higher for digital procedures, some sites may not have enough volume to justify purchasing a system, says Bonnie Rush, RT(R)(M)(QM). This is true even though digital systems can also increase productivity.

Pisano says that she hopes digital manufacturers will lower their prices in coming years. Mammography sites can help that process along by negotiating with manufacturers for price reductions, she says.

For sites that make the digital purchase now, she says it is critical for them to try the equipment before they buy. "Make sure it is comfortable," says Pisano. "You need to test it out."

Although mammography seems to be going all digital, RTs should be certain to let the public know that film equipment is still a powerful cancer detection tool, says Pisano.

It is critical that women don't decide to skip a mammogram if they don't have access to digital equipment, says Pisano, especially because many of them may not have access to digital equipment for some time. Currently, only 8% of mammography facilities have digital equipment and until prices come down, many more may be without it for years to come.

The study, called Diagnostic Performance of Digital versus Film Mammography for Breast-Cancer Screening, will appear in the October 27 New England Journal of Medicine and is posted on the journal's Web site at www.nejm.org .

Insider sources

Etta Pisano, MD, principal investigator, DMIST.

Bonnie Rush, RT(R)(M)(QM), president of Breast Imaging Specialists, San Diego.

Name: Digital Mammographic Imaging Screening Trial

Conducted by: American College of Radiology Imaging Network

Purpose: To study the "small but potentially clinically important differences in diagnostic accuracy between digital and film mammography," wrote study authors.

Enrollment: 49,528 women

Average age of women: 54.6

Eligibility: Women who came in for a screening mammogram at the study sites were eligible to participate unless they

lumpectomy and radiation

Study sites: 33 sites in the United States and Canada

The digital equipment used: Five different types of digital equipment were used in this trial. They included the following:

The process: Women underwent both a digital and film mammogram in random order. Two radiologists independently interpreted the examinations for each woman. Readers rated the mammograms using the seven-point BI-RADS malignancy scale. Breast density was also recorded using the BI-RADS scale.

When a woman had a suspicious finding, she underwent a biopsy or aspiration of the suspicious-appearing lesion. All participants were asked to return for a follow-up mammogram after one year.

A participant was considered to be positive for cancer if the cancer was verified within 455 days of the initial study mammogram. A participant was considered to have a negative finding if tests on a pathology report were normal or if the follow-up mammogram at one year did not show any cancer.

Note: Because the length of time allowed for cancer detection, the sensitivities of both digital and film equipment appeared lower than sensitivities in other similar studies.

Cancers diagnosed: During the course of the trial, 335 cancers were diagnosed. Of these cancers

CMS has released version 11.3 of the National Correct Coding Initiative (NCCI) edits. These edits took effect October 1 for claims filed to Medicare carriers. Hospital claims will not be subject to the version 11.3 edits until January 1.

Reconstruction (76375) is now a component of all the diagnostic nuclear medicine studies listed in CPT with the exception of dual photon absorptiometry bone density exam (78351), which is not covered by Medicare. These edits can be overridden with a modifier, which would be appropriate if reconstruction of a tomographic exam (e.g., CT) were performed on the same day as a nuclear medicine study.

Subcutaneous or intramuscular injection (HCPCS code G0351) is also a component of most nuclear medicine studies under the new edits. The edit can be overridden with a modifier (e.g., if a patient receives an injection that is unrelated to the nuclear exam).

CT without contrast is now a component of PET (78811-78813) and PET-CT (78814-78816) tumor imaging studies. For example, CT of the brain (70450) is now a column two code for column one codes 78811-78816. CT with contrast and CT without and with contrast are not included in this batch of new edits. The edits can be overridden with a modifier, presumably if a diagnostic CT scan is performed on the same day as a PET or PET-CT study.

Limited area PET tumor imaging (78811) is now a component of the skull base to mid-thigh exam (78812) and whole-body exam (78813). It is also a component of all the PET-CT exams (78814-78816). Similarly, skull base to mid-thigh PET (78812) is a component of whole-body PET (78813) and all of the PET-CT tumor imaging exams (78814-78816).

Whole-body PET (78813) is also a component of all the PET-CT codes. These edits cannot be overridden with a modifier.

Limited-area PET-CT (78814) is a component of the skull base to mid-thigh PET-CT exam (78815) as well as the whole-body PET-CT (78816). Skull base to mid thigh PET-CT is a component of whole body PET-CT (78816). These edits cannot be overridden with a modifier.

Subcutaneous or intramuscular injection (G0351) and IV push (G0353-G0354) are now components of various interventional radiology procedures, including

0037T)

36247)

All of these edits can be overridden with a modifier.

Percutaneous transluminal angioplasty (PTA) (35458 and 35475) is now bundled into cervical carotid stent placement (37215-37216).

This edit makes sense because by definition, carotid artery stent placement includes PTA. The edit can be overridden with a modifier for PTA of other locations.

Various injection and infusion codes (including G0345, G0347, G0351, G0353, and G0354) are now components of bone marrow aspiration and biopsy (38220-38221), posterior fossa myelography (70010), and cisternography (70015). These edits can be overridden with a modifier.

Clinical brachytherapy services (77750-77790) now include various additional evaluation and management (E/M) services such as hospital discharge day management (99239) and neonatal intensive care (99298-99299).

CMS has deleted edits that bundled E/M services into stereotactic radiosurgery (code 61793). Also gone are edits that bundled actinotherapy (96900) and photochemotherapy (96910-96913) into radiation treatment delivery (77402-77416) and port films (77417).

CMS has also deleted edits that bundled confirmatory consultations and prolonged E/M services into simple interstitial radiation source application (77776). Additionally, photodynamic therapy (96567) no longer includes radiation treatment delivery (77401-77416) or port films (77417).

The modifier status has been changed from 0 (no modifier will override the edit) to 1 (modifier is allowed) on edits that bundle various E/M services into simple interstitial radiation source application (77776). Among the E/M services affected by this change are nursing facility assessments and subsequent nursing facility care.

Insider source

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.

Facilities that were in the path of Hurricane Katrina have suffered many losses, among them paperwork regarding the qualifications of employees.

On September 16, the FDA announced plans to provide temporary documentation to any employee at a facility that had its initial employee qualification records damaged. The FDA will provide a letter verifying the initial qualifications of the employee based on information from the facility's most recent inspection.

All Mammography Quality Standards Acts (MQSA) inspectors have been told to accept the letters from the FDA as adequate verification that the employee's initial qualifications were met at the time of the last MQSA inspection.

The letters may also be used for employment purposes, although personnel who use one must provide a copy of the state license or certificate at the next annual inspection.

To request a letter from the FDA, fax a request to 410/290-6351 or e-mail MQSAhotline@SSSI.net, attention: Hurricane Katrina. Free book for best radiology report documentation

HCPro, Inc., is currently developing a radiology billing/coding reference devoted to all modalities-sort of a one-stop-shopping guide. We are seeking "real life" radiology reports done by physicians-both the good and the bad-to use as case scenarios. We are looking for examples of any radiology procedures.

What's in it for you? If you share your reports, we will take out any identifying information, including the doctor's name/name of your organization. In exchange for your contribution, you will automatically receive a special discount on the reference once it's published and be acknowledged in the publication (if you choose). If you submit one of the top 10 reports as judged by our authors, you will receive a complimentary copy of the book and be acknowledged for your efforts.

If interested, please submit your reports privately-as many as you want-one of three ways: by e-mail to editor Bryan Cote at bcote@hcpro.com; by mail to HCPro, 200 Hoods Lane, Marblehead, MA 01945; or by fax to 781/639-2982. Include your name and phone number with all submissions. If possible, please remove all demographic information before sending to ensure confidentiality.

You can only use CPT code 93544 for a cardiac catheterization procedure because it is indented and the code description before the semicolon states "injection procedure during a cardiac catheterization procedure." The aortography performed during an angiogram (peripheral or otherwise) is included as part of the angiogram procedure, so do not code it separately.

Medicare is explicit about correct diagnosis coding for outpatient services. The applicable CMS program memorandum is AB-01-144. It explains that you must code the final diagnosis on the radiology report. Refer to Section 10.1.1 in Chapter 23 of the Medicare Claims Processing Manual, item A.

If the physician confirms a diagnosis based on the diagnostic test results, the physician interpreting the test should code that diagnosis. The signs/symptoms that prompted the physician to order the test may be reported as an additional diagnosis if they are not fully explained or related to the confirmed diagnosis.

Although it is not incorrect to assign a sign or symptom as an additional code along with the first listed code (as determined from the result of the radiology report), establish a policy at your facility governing whether to report additional diagnoses. This procedure will ensure consistency of code assignment by your staff.

The program memorandum provides specific clinical examples as well as the Claims Processing Manual. If the final diagnosis is "routine" or "normal," code the sign or symptom from the script.

Given the scenario provided, bill using 74170 based on the current Outpatient Prospective Payment System/Outpatient Code Editor (OCE) payment logic. This is true even though it appears that the physician ordered both examinations separately, the examinations were performed separately, and the results were reported separately with distinct individual reports.

When you bill for both exams separately using 74150 and 74160 (with or without modifier-59 present), they trip Edit 20 of the OCE, which states,"Code a pair that is not allowed by NCCI, even if an appropriate modifier is present."

Until such time as CMS deems this scenario appropriate and removes it from the OCE, failure to bill in this manner will result in the line item rejection of CPT 74150.

Insider source

Glenn Krauss, RHIA, CCS, CCS-P, CPUR, independent consultant, Maryville, TN.