• E-mail
• Print
• PDF

Learn to dodge radiology coding trouble spots in 2006

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

CMS released several coding changes effective January 1. A few of these changes raised radiologists’ eyebrows and ire. The following represent hot topics that arose during two audioconferences (see the end of the article for details):

Q: Do we need to worry about medical necessity with low osmolar contrast materials (LOCM)?

A: Medical necessity for the use of LOCM versus high osmolar contrast materials causes much consternation with CMS and other third-party payers, said Duane C. Abbey, PhD, CFP, president of Abbey & Abbey, Consultants, Inc., in Ames, IA.

However, CMS Program Memorandum A-02-120, April 1, 2003, significantly mitigated the agency’s requirements for hospitals to justify the use of LOCMs, Abbey said.

Additional guidance shows reduced special medical necessity requirements for nonhospital providers. Transmittal 627, offered from CMS on July 29, 2005, eliminates “the restrictive criteria for payment of LOCM for nonhospitals.” The agency applied the same criteria, extending LOCM reimbursement to hospitals in the final regulations released in 2006 (CMS-1501-FC), said John Marshall, CRA, RCC, RT (R), of Coding Strategies, Inc., in Powder Springs, GA.

Some hospitals use only LOCMs, said William L. Malm, ND, RN, of Health Revenue Integrity Services in Cleveland. These hospitals resolved the issue of medical necessity by setting LOCMs as the standard practice as a matter of policy, he said.

Such a policy “won’t protect you 100%, but you will be on good ground [regarding] medical necessity,” said Abbey.

Q: Should LOCM be bundled or unbundled?

A: LOCM is now considered to be a drug, is no longer bundled for reimbursement, and should be billed separately, said Marshall.

CMS reduced the payment for CT scans with contrast to compensate for the additional LOCM payment. Specifically, 42 CFR Parts 419 and 485 (CMS-1501-FC) on p. 291 states “APC’s [ambulatory payment classification] 0283 and 0333 decreased by less than 3%.”

It continues on p. 291 and p. 293: “Our proposal to pay separately for LOCM . . . may increase overall payments for some contrast-enhanced CT studies . . . which include unpackaging LOCM.”

The documentation states “unpackaging” LOCM, not “bundling” it, he said.

Q: Do you have any tips for billing for conscious sedation?

A: CMS does not make separate payments under its APC system, said Abbey.

“Look for the bulls-eye beside your [CPT] code,” said Marshall. “Many radiology procedures include moderate sedation as part of the procedure. These obviously cannot be billed separately. Moderate sedation can be billed with other procedures but are only paid on the physician side.”

When billing for moderate sedation by a second physician, an anesthesiologist, or another doctor, coding depends on the patient’s age and the duration of the service, Marshall said.

If the patient is younger than five, use code 99148 for the first 30 minutes of intraservice time. If the patient is age five or older, use code 99149 for the first 30 minutes.

Use code +99150 as an additional code for each additional 15 minutes of sedation, Marshall said.

Q: What is the best use of modifier 51?

A: Modifier 51 is a physician-only modifier, Malm said. Neither hospitals nor radiologists generally use it, he added.

Physicians use modifier 51 in tandem with surgical codes to indicate the performance of more than one surgical procedure, said Abbey.

“With today’s claims adjudication systems, this modifier is really unnecessary,” he said.

Such systems often use the codes on the claim itself to automatically determine whether multiple surgical procedures were performed.

Q: Can we use modifiers 52, 73, and 74 for a breast biopsy with local anesthesia?

A: The relationship between these three modifiers can be confusing, said Malm.

Use the 52 modifier if there is a reduced service and anesthesia is not involved, said Abbey.

“Starting in 2006, the 52 modifier is now a payment modifier that reduces payment by 50%,” he said.

If a patient who is scheduled to have a breast biopsy is fully prepared with local anesthesia but the procedure is discontinued, then you can consider the 73 or 74 modifiers, according to Abbey and Malm.

Editor’s note: The information contained in this article came in part from the HCPro, Inc., audioconference “Diagnostic Radiology Coding: Recovering Revenue and Understanding the 2006 Changes,” which took place January 12 (for information, call the HCPro Customer Service Department at 800/650-6787) and the American Healthcare Radiology Administrators audioconference “2006 Radiology Coding Update,” which took place April 11 (for information, visit www.ahraonline.org or call 800/334-2472).

Insider sources

Duane C. Abbey, PhD, CFP, president, Abbey & Abbey Consultants, Inc., Ames, IA; duane@agciweb.com.

William L. Malm, ND, RN, Health Revenue Integrity Services, Cleveland, OH; wmalm@adelphia.net.

John Marshall, CRA, RCC, RT (R), Coding Strategies, Inc., Powder Springs, GA; john.marshall@codingstrategies.com.

• E-mail to a Colleague
• Print