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Radiology Administrator's Compliance & Reimbursement Insider, May 2006

Radiology Administrator's Compliance and Reimbursement Insider, May 1, 2006

Inside:

Unlock success with strategy, research

MRI, ultrasound, scintimammography, and PET no substitute for biopsy

Updated definitions, coding for conscious sedation

 

Unlock success with strategy, research

All patients within a 10-mile radius of your radiology facility come to you without question for their imaging needs. You’ve reached the top of your income-earning ability. You’ve maxed out your market.

Now what?

It’s time to consider creating a strategic plan, said Elsa Ozuna-Richards MSA, CMPE, of REA Healthcare Strategies in Reno, NV, who spoke during an American Healthcare Radio logy Administrators (AHRA) audioconference in January.

However, you don’t have to be sitting on top of the radiology world to need a strategic plan, Ozuna-Richards said. Whether your facility operates at the pinnacle of financial prosperity or—like many facilities these days—struggles to pinch pennies, a strategic plan helps your business find its focus and earn greater profits.

Where to start

Before you formulate a strategic plan, make sure that you know your practice inside and out. Know it not just from your own perspective, but through the eyes of
your employees, shareholders, business partners, and customers.

A strategic plan helps everyone involved steer the organization through rocky financial waters or stormy, competitor-tossed seas to the distant shores of future success.

Ensure top-level commitment to the strategic plan proc ess before you begin, Ozuna-Richards said. Nothing moves forward unless the power brokers are involved.

Allocate adequate time and money to the process and to implementing key components of the completed plan.

Don’t propose any other major moves for at least six months.

A strategic plan may bring turmoil and change of its own.

When brought together with preexisting challenges, your proposals may get lost in the shuffle—or worse, tossed aside amid growing angst and worry associated with change, said Ozuna-Richards.

Look to staff for strategic solutions

Alleviate tension by helping staff understand the importance of future planning and encourage their involvement. Their participation in the process increases the likelihood of their investment in its outcomes.

Decide which staff to include as key players on your development team. Ozuna-Richards recommended involving a wide spectrum of representatives from receptionists to physicians, community leaders to volunteers, and topic experts to patients.

Place participants within the appropriate stages of strategic development and create a timeline for their involvement.

Facility leadership should participate in the initial mission- and vision-setting segments of the plan. They may wish to step out of the research and assessment phases and return during the priority-setting portion of the strategic planning process.

“Before implementation is really [when] you want your staff to be involved,” she said.

Define your mission, set your vision

A mission statement summarizes your business values and organization. Vision statements set your company’s sights on the future, said Ozuna-Richards.

Create mission and vision statements and communicate them to your customers and staff, she said.

“Hang your mission statement on the wall so you never lose track of it,” said Ozuna-Richards.

One facility that she assisted set its sights on becoming the premiere neurosurgery center in its area.

Stating its mission, the group then focused on all areas of its business to reflect that goal. It reviewed its hiring policy, front-end staff training, and new technologies to ensure that those areas fell in line with the facility’s mission.

The neurosurgery unit’s vision for the future therefore reflected its overall objective by stating the business’ intended goals: “We will be the region’s premier practice for all spine and brain procedures.”

More about research

Research is critical to strategic development because it is the primary phase of strategic development, Ozuna-Richards said.

How you collect data is as important as the information you gather, she said.

Complete primary research through telephone or mail surveys or one-on-one interviews with individuals. Be consistent. Develop a script to ensure that surveyors ask similar questions. Allow for anecdotal information at this stage, but aim to gather statistical data to compile for use later on.

Secondary research completed via database, the In ternet, or industry associations also helps create a comprehensive overview of how your business fits into the larger industry.

Select a strategy

Put all of these collected data to good use. Define your facility’s strengths, weaknesses, opportunities, and threats to market growth, said Ozuna-Richards.

Develop strategies to capitalize on your strengths. Look for growth opportunities to handle perceived flaws and threats to your financial viability. “Match opportunities with weaknesses,” she said.

For example, one weakness may be location. Perhaps your business lies outside of the comfortable commuting zone for patients in a developing community. Opening a second facility there or creating a shuttle service from that area may prove to be a previously unexplored opportunity.

Set priorities

You’ve gathered all of these great ideas about how to expand your influence and increase your business’ bottom line. Unfortunately, neither the money nor the time exists to implement them all.

Focus and get your priorities in order, Ozuna-Richards said.

Pool the various strategies and take a diplomatic approach to selecting objectives, she suggested. This way, everyone owns a piece of the strategic plan process and participates in the company’s success.

Include both short- and long-term objectives in your priorities. Couple goals with a timeline and describe how and when things must get done.

Think of short-term goals as steps leading to accomplishing long-term objectives.

For example, if you set one of your long-term goals on networking with area physicians, then your short-term targets should include items to get you there. Actions such as joining regional chambers of commerce, hosting an educational series, and launching an advertising campaign all lead to increased networking, said Ozuna-Richards.

Focus on achievable goals based on your mission, and integrate the plan so each element supports the next priority. This creates momentum for the proposal to propel itself—and your business—forward.

Guarantee that the strategic plan doesn’t become a static document by holding monthly strategy meetings. Revisit the plan three months from the time it’s solidified, and refine your strategic plan annually.

The final strategic step

The best plans establish measurable returns to short- and long-term goals.

Monitor and evaluate your progress as you accomplish the goals shaped by your strategic plan.

For example, ask referring physicians how they heard about you. Document the number of patients you gained due to your various short-term goals (e.g., joining area chambers of commerce). Also set a rate of growth that you expect from each short- and long-term goal at the outset.

Understand the amount that you wish to grow annually and the percentage of growth that you need to maintain your current profit margin, staff, etc.

Reaping the strategic benefits

Expect enormous payback from your strategic plan, said Ozuna-Richards.

You’ll find that your business and employees

  • spend more time on high-impact activities
  • understand true opportunities
  • become more dedicated to the business
  • adapt quickly through change and innovation
  • are proactive instead of reactive

    Today’s customers operate differently from those of a decade ago, Ozuna-Richards said. With the Internet and a multitude of products available at their fingertips, customers search for something better, special, and just for them.

    A strategic plan helps you determine what special service you provide and focuses attention on it for all potential customers to see.

    To be successful, you need to complete a strategic plan and use it, said Ozuna-Richards.

    “Eighty-percent of strategic plans sit on the shelf. Don’t let that happen to you,” she said.

    Insider source

    Elsa Ozuna-Richards, REA Healthcare Strategies, Reno, NV, 775/829-2299, Ext. 203; elsa@realstrategies.com.

    Use these tips to gauge growth and competition

    Assess your current environment

    When looking toward your business’ future, look also at its present practices, said Elsa Ozuna-Richards, MSA, CMPE, of REA Healthcare Strategies in Reno, NV, during an audioconference in January.

    “Marketing research is critical for any organization to anticipate the future,” Ozuna-Richards said. She divided such research into two categories—internal and external.

    The in-house breakdown

    Interview employees to complete an internal analysis. Determine whether they understand the company’s overall mission. Also examine your policies and procedures to ensure that all aspects of your daily activities reflect your global business goals.

    Ask yourself and your staff the following questions:

  • Which type of services does your business provide?
  • What are your strengths and weaknesses?
  • Do you have any new services or capabilities for new services?
  • How does your business compare to competitors?

    Complete the picture with outside inquiries

    An external analysis investigates consumer and public relations aspects of your business.

    Leaders of a neurosurgical center mentioned by Ozuna-Richards believed that their customers chose them based on networking and relationship building.

    However, as it turns out, customers—both patients and referring physicians—chose the unit for its quality reputation. The neurosurgery group decided to capitalize on this market strength.

    Like those at the neurosurgery unit, learn how your customers view you.

    “You [wouldn’t] believe how many people think their strength is one thing when it’s really something else entirely,” said Ozuna-Richards.

    Ask these questions to create a comprehensive business plan

    Just because your radiology center sits at the corner of Broadway and Main Street doesn’t necessarily mean that clientele will come knocking at your door.

    And although that new, 64-slice CT scanner may make your competition appear more appealing at first blush, you have something that it doesn’t have.

    You just have to determine what that something is.

    To accomplish this task, ask your customers why they patronize your practice. Elsa Ozuna-Richards, MSA, CMPE, who spoke during a January American Healthcare Radiology Administrators audioconference, recommended asking the following questions:

  • Which products or services engage the customer?
  • Which products or services trigger the customer’s emotions?
  • How frequently do your customers refer your practice to others and why?
  • What products or services do your customers need?
  • What demographics do your customers represent (e.g., age, gender, ethnicity, education, etc.)?

    Don’t neglect a thorough examination of your competitor’s business.

    You may not be able to buy the same equipment that the radiology facility down the street can, but perhaps it can’t match your technical skills or diagnostic capabilities.

    Ozuna-Richards recommended asking the following questions to investigate your competition:

  • Who is the competition and which services does it provide?
  • What segment of the radiology business market does it serve?
  • What is its market share?
  • How does it spread the word about its practice?
  • How has it positioned itself and what is its attitude about the services it provides?

    “You in radiology are lucky because it is a data-rich environment. You have all [of] this information . . . right at your fingertips. You can segment [those] data any way you choose, by customers, referrals, [etc.]” Ozuna-Richards said.

    Other external factors to examine include technological advancements, political issues, governmental mandates, and the general conditions of your state and national economies.

     

     

    MRI, ultrasound, scintimammography, and PET no substitute for biopsy

    The Agency for Healthcare Re search and Quality (AHRQ) releas ed a report in February concluding that PET, scintimammography, ultrasound, and magnetic resonance imagery (MRI) should not be used in lieu of a breast biopsy to detect cancer.

    All of these modalities had an error rate that made the risk of missing cancer too high, according to the report.

    The study does not contain any new information, says Leonard Berlin, MD, chair of the radiology department and professor of radiology at Rush Medical College in Chicago.

    “No one in mainstream radiology has ever come forth to say that ultrasound or MRI . . . [are] as good as or will replace biopsy,” he says.

    He says the fact that these procedures should not be used as a re-placement for a breast biopsy in no way diminishes their usefulness in cancer detection and evaluation.

    About the study

    The study focused on 81 studies de-signed to evaluate the accuracy of MRI, PET, scintimammography, and ultrasound in diagnosing of breast cancer.

    Each was rated in terms of sensitivity, specificity, and negative likelihood ratios.

    The study authors found that for every 1,000 women who underwent

  • a PET scan, 924 could have safely avoided a biopsy, but 76 would have missed cancers
  • an MRI, 962 could have avoided a biopsy, but 38 would have missed cancers
  • a scintimammogram, 907 would have avoided a biopsy, but 93 would have missed cancers
  • an ultrasound, 950 would have avoided a biopsy, but 50 would have missed cancers

    According to the study authors, an acceptable standard has been established: If there is an imaging procedure that has a less-than-2% risk of missing cancer, that test would be a suitable alternative to a biopsy. By this definition, all of the above tests fall short and should not be routinely used instead of biopsy.

    In its criticism of the studies, the ACR said its authors did not distinguish between an inconclusive screening mammogram and a mammogram that, after a thorough workup, is assessed as a suspicious finding. A woman with a suspicious abnormality on her mammogram needs a biopsy. However, additional testing— particularly ultrasound—is a crucial step in the thorough evaluation of an inconclusive mammogram.

    Editor’s note: Published in the March HCPro, Inc., publication Mammography Regulation and Reimburse ment Report.

     

     

    Coding corner

    Updated definitions, coding for conscious sedation

    by William Malm, ND, RN

    Radiologists continue to struggle with how to define and bill conscious sedation. Below are updated guidelines, definitions, and coding suggestions for outpatient prospective payment system hospitals.

    Define anesthesia

    Providers deliver anesthesia by many methods, so it’s important for coding purposes to understand the accepted terms used to define these methods and levels of sedation. The American Society of Anesthesiolo-gists House of Delegates approved the following levels in October 1999:

  • Minimal sedation (anxiolysis): Cognitive function and coordination may be impaired. Patients re-spond normally to verbal commands. There is no effect on cardiovascular or ventilatory functions.
  • Moderate sedation/analgesia (conscious sedation): Depression of consciousness in which pa-tients respond purposefully to verbal commands. No intervention is required to maintain airway or spontaneous respirations, and there is no effect on cardiovascular function.
  • Deep sedation/analgesia: Depression of consciousness during which patients cannot be easily aroused. Ventilatory function may be impaired without a change in cardiovascular function.
  • General anesthesia: Drug-induced loss of consciousness; patient is not arousable even to painful stimuli. Patients generally require ventilatory assistance, and cardiovascular function may be impaired.
  • Monitored anesthesia care (MAC): Separate from the four levels of anesthesia and does not describe the depth of sedation listed above. MAC describes a specific anesthesia service requested by the operating physician of the anesthesiologist. The latter participates in the care of the patient undergoing a diagnostic or therapeutic procedure.

    During MAC, the anesthesiologist may monitor vital signs, perform maintenance of the patient’s airway, administer sedatives, analgesics, or other medications as necessary, and assist with other problems. For example, an elderly patient who has chronic obstructive pulmonary disease may require an anesthesiologist to ensure cardiovascular and respiratory integrity.

    Note 2006 definition, billing changes

    The American Medical Association (AMA) recently released new coding guidelines for conscious sedation, which took effect January 1. Note that conscious sedation does not include minimal sedation, deep sedation, or general anesthesia. The charge for conscious sedation includes the following elements (therefore, do not bill these elements separately):

  • Assessment of the patient
  • Establishment of IV access
  • Administration of agent(s)
  • Maintenance of sedation
  • -Monitoring of oxygen saturation, heart rate, and blood pressure
  • Recovery

    (Source: CPT Changes 2006—An Insider’s View,
    p. 270–274, AMA.)

    The AMA deleted codes 99141 and 99142 and replaced them with six new codes, 99143–99145 and 99148– 99150. The AMA then divided these new codes into the following two groups (note that physicians do not include anesthesiologists):

  • -Single physician with a single observer (99143– 99145)
  • -Two physicians with a single observer (99148– 99150)

    The AMA also broke physicians into the following two categories for the purpose of billing the proper code:

  • -One physician (i.e., the physician performing the procedure) and one trained observer (e.g., a nurse)
  • -Two physicians (i.e., the physician performing the procedure and a second physician, who provides the moderate sedation within a facility setting)

    The codes no longer refer to the route of administration; instead, they reflect the level of physician-involvement stated above, the patient’s age, and the time of sedation. Note that the time of sedation does not include assessment or recovery time. Rather, the AMA defines the time of sedation as the “time of the administration of the sedation agent, [which] requires face-to-face attendance and ends at the conclusion of personal contact by [the] physician providing the sedation.” (Source: CPT 2006 manual, p. 409, AMA.)

    Many providers are also confused about when they should code and bill conscious sedation. CMS has stated that certain procedures include conscious sedation, meaning that it is inherent to the procedure and therefore not separately billable. The CPT 2006 manual lists these procedures in Appendix G and also includes a bull’s-eye symbol to the left of the specific CPT code descriptions within the book.

    You will find almost all of the bull’s-eye procedures listed in specific areas in the CPT 2006 manual because sedation is inherent in certain types of procedures. For example, bronchoscopy, gastrointestinal/endoscopy procedures, and most of the cardiac catheterization and interventional radiology procedures are included in Appendix G and have bull’s-eyes next to their descriptions.

    Appendix G contains radiology codes 77600, 77605, 77610, and 77615 for hypothermia during radiation treatments.To prevent denials, teach radiology professionals in your hospital to review Appendix G for a surgical component code. For example, a balloon angioplasty of the iliac artery (35473) is a procedure that includes moderate sedation. Therefore, do not bill separately for conscious sedation in this instance.

    Learn how to code conscious sedation

    From a chargemaster, coding, and billing perspective, hospitals face a dilemma: How are they to capture charges for conscious sedation? CPT codes 99143– 99150 have a status indicator N, meaning that their reimbursement is packaged within the procedure. Here are some guidelines to follow:

  • For procedures listed in Appendix G of the CPT 2006 manual, include the cost of the delivery of the sedation within the charge for the procedure. For procedures not found within Appendix G, your facility must determine how to record and bill these codes.
  • CMS instructs facilities to represent the sedation charge (even though it is packaged) on the claim when the sedation is not associated with a procedure listed in Appendix G. CMS requests that you include these codes on the claim for reporting purposes, when applicable. This will require significant coordination and training to use these conscious sedation codes correctly.

    Although CMS requires hospitals to record these procedures, many facilities have opted to not charge or bill for conscious sedation at all. Therefore, they have built the cost of the conscious sedation delivery into the price of the procedure. These hospitals reason that this does not result in overpayment and therefore does not represent a compliance concern, whereas the inaccurate reporting of bundled codes does.

    How to record and bill for conscious sedation is truly a facility-specific decision. Make this decision in conjunction with the appropriate compliance professionals within your organization. For further clarification and guidance, consult your fiscal intermediary.

    Insider source

    William L. Malm, ND, RN, Health Revenue Integrity Services, Cleveland, OH, 440/331-3312.

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