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Radiology Administrator's compliance & Reimbursement Insider, September 2006

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

Inside:

Keeping beat with cardiac imaging

Special certs for special talents

Documentation makes all the reimbursement difference

Understand signature rules for diagnostic documentation

Follow these recommendations for CT and CTA coding

New cert requirements for rad techs considered

Keeping beat with cardiac imaging

Understand code changes to reap reimbursement

There’s no denying that cardiac imaging is the next big development in healthcare.

“Radiology is one of those fields [in which], when something new comes out, everyone has to have it. [Most] consumers are well aware of the improvements in cardiac imaging technology. They want the latest noninvasive scan,” says Stacy Gregory, RCC, CPC, president of Gregory Medical Consulting Services in Tacoma, WA.

That’s why Medicare and other payers watch reimbursement for cardiac imaging procedures so closely, she says.

“Heart image codes are among the most used, which is probably why CMS put them on its most watched list,” said Walter C. Blackham, MS, RCC, president of Specialty Medical Services, Inc., in Lorain, OH, during the June Radiology Business Management Association meeting in Miami.

Straight from the heart

Concern over compensation associated with cardiac imaging is one of the biggest issues in imaging today, says Shelley Weiner, MD, FACR, senior medical director at CareCore National in Wappingers Falls, NY.

Although government and private payers are beginning to provide payments and guidance concerning such innovative imaging procedures, financial support varies according to carriers coverage policies.

“Technology is changing so fast, and the rules are changing just as fast,” says Diane Millman, an attorney with Washington, DC–based Powers Pyles Sutter & Verville, PC, who represents an association of cardiologists.

“It’s a ‘now you see it, now you don’t’ world in terms of technology,” she says.

Because of this increased public interest, the American College of Radiology and American College of Cardiology joined forces with BlueCross BlueShield to create new Category III CPT codes for cardiac imaging.

The new codes, which took effect January 1, describe various common combinations of cardiac CT and CTA studies, says Gregory.

In most cases, the CPT uses a single code to describe the combination of services performed.

Battle plans

Just knowing the codes may not be enough to win you compensation for cardiac imaging procedures, warned Melody W. Mulaik, MSHS, CPC, CPC-H, RCC, of Coding Strategies, Inc., in Powder Springs, GA.

Mulaik presented diagnostic coding conundrums during the American Healthcare Radiology Administrators’ audioconference “Diagnostic Radiology: Hot topics and updates” on June 28.

“We are not seeing across the board that people are getting reimbursement for these procedures,” she said.

“It may be a really great procedure but we’re just beginning to find out what’s being paid and what isn’t in regard to CT/CTA coronary.”

There are no relative value units for Category III CPT codes, said Mulaik.

Physician reimbursement for these services depends on carrier fee schedule and local coverage determinations (LCD) requirements, she said.

The majority of payers—private and Medicare alike—do not currently reimburse for cardiac CT angiography (CCTA) or calcium scoring, says Gregory.

Blackham said most payers appear willing to pay for CPT code 0146T—CT, heart, without contrast material, followed by contrast materials and further sections, including cardiac gating and 3D image postprocessing; CTA of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts) without quantitative evaluation of coronary calcium.

“[Because] it’s the most popular study, it’s probably also going to be the most watched study, as well,” said Blackham.

Investigational trouble

Many payers, carriers, and fiscal intermediaries still consider cardiac imaging procedures investigational procedures, Gregory says.

Without specific CMS guidance or instructions to the contrary, providers and other healthcare professionals should use Category III codes, by CPT definitions, for the purpose of tracking new and emerging technologies, Gregory says.

“In most cases, medical benefits for these services have not yet been defined or validated,” she says. Further, there is no guarantee of reimbursement, she says.

Slicing the pie

David Dowe, MD, a radiologist with AtlantiCare Regional Medical Center in Atlantic City, NJ, sees big financial challenges in cardiac imaging.

“It comes down to splitting the [radiology reimbursement] pie into smaller and smaller pieces for reimbursement money that is not there to begin with,” says Dowe. “It’s an insurance issue. Management is making it hell to get any exam, never mind a cardiac CT.”

There are exceptions that are specifically described in various CMS instructions (e.g., change requests, manuals, or LCDs), and contractors may make individual considerations—in which case the code may be billed and reimbursed according to their fee schedule, says Gregory.

Those payers/carriers who do cover CCTA have specific policies, clinical indications, and criteria to meet to receive reimbursement for the procedure.

Mulaik suggested researching the payment practices of the top 10 payers in your area to determine whether each offers payment for cardiac imaging.

“Don’t rely on rumors about who’s paying for what,” she said. “Do the research.”

“The papers are saying that [cardiac imaging] is extraordinary, that it’s a miracle,” Dowe says.

“Soon it will be that everyone 30 or 40 [years old] or older will have a heart scan as part of their routine physicals,” he says. “But how are we going to pay for that?”

Insider sources

Walter C. Blackham, MS, RCC, president, Specialty Medical Services, Inc., 221 West 8th St., Lorain, OH 44039, 440/245-8010, Ext.10; Walt@spmeds.com.

David Dowe, MD, AtlantiCare Regional Medical Center, 1925 Pacific Ave., Atlantic City, NJ 08401-6713, 609/652-3400.

Stacy Gregory, RCC, CPC, president, Gregory Medical Consulting Services, 2661 N. Pearl St. #364, Tacoma, WA 98407, 253/566-2494; stacy@gregorymedicalconsulting.com.

Diane Millman, Powers Pyles Sutter & Verville, PC, 1875 Eye St., NW, Twelfth Floor, Washington, DC 20006, 202/466-6550; diane.millman@ppsv.com.

Melody W. Mulaik, MSHS, CPC, CPC-H, RCC, Coding Strategies, Inc., 5041 Dallas Highway, Suite 606, Powder Springs, GA 30127, 877/6-CODING; melody.mulaik@codingstrategies.com.

Shelley Weiner, MD, FACR, senior medical director, CareCore National, LLC, 169 Myers Corners Road, Wappingers Falls, NY 12590, 845/298-8155; sw@carecorenational.com.

Special certs for special talents

SIIM readies qualification program for PACS administrators

Everything is digital these days—x-rays, ultrasounds, and even your grandmother’s recipes.

Managing the electronic information flow associated with Italian wedding soup may not require specialty knowledge, but moving billions of bytes of imaging data from radiologists to physicians and patients and back again requires a certain kind of intellectual fortitude.

That’s why hiring a Picture Arch-iving and Communication System (PACS) administrator can be such tricky business.

The term “PACS administrator” previously applied to someone with any radiology, medical, technical, or informational skills. But the Society for Imaging Informatics in Medicine (SIIM) wants to quantify those skills by establishing a new set of certification criterion.

SIMM recently announced sponsorship of Certified Imaging Informatics Professionals, a new certification initiative to professionalize the PACS administrator position.

The PACS Administrators Registry and Certification Association (PARCA) established a certification program in early 2005, and other radiology groups have offered their own fee-based certifications.

But SIIM hopes to standardize its program through the National Commission for Certifying Agencies, which officially endorses certification bodies, J. Anthony Seibert, MD, professor of radiology at University of California Davis and chair of the SIIM certification committee, tells RACRI.

“We want to separate ourselves from other certification processes,” he says.

Charles Socia, vice president of operations for Synergy Imaging in Little Rock, AR, and a member of the committee adds that “PARCA and some other organizations are set up like schools—you pay to take their exam—whereas our certification exam more resembles a medical professional exam, such as that for respiratory therapists.”

SIIM hopes that certification creates an accurate measure of the knowledge and skills of imaging informatics professionals, offering a means for employers to better evaluate their qualifications for PACS-related positions.

The committee put draft test content online (www.scarnet.net/ciip) and is soliciting input from PACS administrators on eligibility requirements and the weighting of the test’s various elements, Seibert says.

He projects that the first test will be available in September 2007, and exams initially will take place twice per year at multiple locations nationwide.

The increasingly technical nature of PACS and the complex range of its functions have produced PACS administrators with widely divergent aptitudes, backgrounds, and experiences. The SIIM certification process reflects the changing nature of PACS managers, Seibert says.

The program will incorporate interpersonal, business, and technical elements, he says.

“We want to make sure that there’s a minimal competence in all three areas. If a facility hires a PACS administrator without looking at [his or her] credentials, it could have a problem. After all, you don’t hire a radiologist unless [he or she is] board certified,” says Seibert.

The committee wants to create a universal certification standard without unfairly disqualifying anyone from taking the exam, Socia says.

“We want to make sure that everybody who should take the test will be able to do so,” he says.

Eligibility requirements for the exam will require two years of experience, plus continuing education and a certain level of performance, Seibert says.

However, “if somebody has a [radiology technologist] background, [he or she] won’t have to have an equally strong IT background to take the test, but will have to have basic knowledge about how the PACS system functions,” he says. (The eligibility formula is available at www.scarnet.net/ciip/eligibility.htm.)

The exam and resultant certification are voluntary, says Socia. Nonetheless, he fully expects that a large number of experienced PACS administrators will participate.

Outcry from experienced PACS administrators over the hiring of less experienced workers became a driving reason for the program, he says.

“There was also confusion over their job description. The catalyst for our job task analysis was our desire to know what PACS administrators really do. After taking our exam, we [believe that] they’ll be able to be competent across the board. The ideal candidate should be able to step into a medium-sized hospital and develop a full PACS program from scratch,” says Socia.

Facilities hiring PACS administrators before the SIIM exam rollout should visit www.scarnet.net/ciip and look at the framework developed by the certification committee, Seibert recommends.

SIIM plans to periodically place sample exam questions on its Web site before the test’s September 2007 debut, which will give prospective employers an idea of whether their PACS administrators are eligible.

“Our hope will be that a full bachelor and/or master’s level degree program will come of our certification program,” Socia says.

Coding corner

Documentation makes all the reimbursement difference

Everyone knows the so-called golden rule of radiology coding—if it isn’t documented, it didn’t happen, and if it didn’t happen, you’re not going to get paid.

But, as everyone knows, providing proper documentation isn’t easy, said Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, vice president of Southeast Radiology Management in Stuart, FL. Buck spoke during a RACRI-sponsored audioconference in April titled “Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement.”

Make sure that physicians, technologists, and coders understand and follow the CPT documentation requirements outlined by CMS and the American College of Radiology (ACR). That alone is a big task, she said.

But it’s an important one, as evidence by a 2004 fraud case that resulted in a Florida radiology facility paying $2.5 million to settle claims that it billed for studies that physicians did not order.

“Practices must know what rules apply to each place of service [i.e., hospital, freestanding, or office setting],” said Buck. “The suit reinforces the need for radiologists to communicate with referring physicians and document their efforts to obtain adequate orders and clinical indications when necessary for a requested study.”

Following are a few of the documentation requirements of which you should be aware:

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