Radiology Administrator's Compliance & Reimbursement Insider, December 2006

The Work Plan also contains an expansive list of activities related to Medicare and healthcare professionals, including hospital capital payments and adjustments for graduate medical education payment, among other items.

Although not a comprehensive query into every avenue of concern, the Work Plan nevertheless provides a valuable tool for radiology administrators.

With it, imaging leaders can prioritize facility or department compliance activities.

The million-dollar question:implications for imaging

As the use of radiology rises, expect OIG scrutiny also to increase.

Although imaging has always caught investigators’ eyes, high-priced procedures and complex coding and billing structures make it an ideal area to target, says Stacey Gregory, RCC, CPC, president of Gregory Medical Consulting Services in Tacoma, WA.

This year, the OIG’s radiology concerns include diagnostic x-ray payments in the emergency department (ED); cardiography and echocardiography billing practices; and the use of advanced imaging procedures in physician offices.

Imaging in offices: ‘Take it or leave it’

The latter Work Plan agenda item may cut to the heart of the imaging use or overuse issue being debated across the country by payers and providers alike.

From 1999 to 2005, the use of advanced imaging services (e.g., magnetic resonance imaging, PET, and CT scans) grew on average by 20% per year.

In 2005 alone, Medicare allowed charges of more than $7 billion for these services, according to the Work Plan.

This year’s OIG review examines the appropriateness of imaging services provided in physician offices and considers the nature of the growth of these services.

To do this, the OIG plans to study billing patterns in certain geographic areas and practice settings over the previous years. The agency has already begun its review.

ED x-ray double-dipping: ‘You’ll be sorry’

Medicare-certified hospitals performed more than 2.5 million diagnostic x-rays in EDs, in 2004.

Is it any wonder that the 2007 OIG agenda includes inappropriate payments for interpretation of diagnostic x-rays in hospital EDs?

Imagine this situation: An elderly man enters the ED in the evening complaining of chest pain. Technologists take an x-ray.

The film and the patient return to the ED. The physician looks at the x-ray, sees a fracture on the man’s ribs, and sends him home.

The next day, however, the radiologist looks at the film and also reports his findings.

On this level, according to the OIG Work Plan, the question is: ‘Who gets to bill for the exam analysis?’

“This is a huge issue,” says Hugh E. Aaron, MHA, JD, CPC, CPC-H, senior vice president, compliance and regulatory affairs/regulatory counsel, at HCPro, Inc., in Marblehead, MA. “This goes back to the rules for appropriate reporting and billing.”

Contractors pay for only one interpretation of an x-ray procedure furnished to an ED patient, according to the Medicare Claims Processing Manual.

Second interpretations require modifier -77, but this should only occur under unusual circumstances, such as if a specialist is needed, the Work Plan states.

Even then, documentation for this type of situation—including information regarding medical necessity—must be present to support the additional claim.

The OIG plans to examine whether the services were medically necessary and whether the tests were interpreted contemporaneously with the patient’s treatment.

Cardiography and echocardiography services

As occurs with many physician services, cardiography and echocardiography include both technical and professional components, the OIG Work Plan states.

When a physician performs the interpretation separately, modifier -26 should be used to bill Medicare.

“Cardiology and radiology are often on the OIG’s watch list,” says Gregory. “They are high-priced procedures, and there’s a lot that goes along with them.”

But when it comes to actually coding and billing for these procedures, physicians often confuse the issue.

“Essentially, the OIG is saying, ‘We want to see if we’re being properly billed.’ That’s very significant, particularly for freestanding facilities and physician practices,” says Aaron.

“I think [the OIG] just wants to make sure that physician practices are using the appropriate modifiers and submitting appropriate bills for the appropriate levels of service,” says Gregory.

Insider sources

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

Hugh E. Aaron, MHA, JD, CPC, CPC-H, senior vice president, compliance and regulatory affairs/regulatory counsel, at HCPro, Inc., 200 Hoods Lane, P.O. Box 1168, Marblehead, MA 01945, 804/965-6387; haaron@hcpro.com.

Coding corner

CPT changes mark manual imaging moves

The 2007 American Medical Association (AMA) CPT manual contains 41 changes to codes that affect radiology and imaging services.

“Because these are codes that are used on an everyday basis, it’s going to be a tough transition,” says Jackie Miller, RHIS, CPC, of Coding Strategies, Inc., in Powder Springs, GA.

Many of the changes involve simply moving codes around to more accurately reflect respective modalities. Other coding alterations better align descriptor language to current procedure paths.

The code relocations represent the AMA’s organizational restructuring (CPT 5 Data Model Project), the American College of Radiology (ACR) says in an October release, “to facilitate computer processing and interoperability with various computer systems.”

The AMA previously placed many new imaging codes in the “other procedures” category, Miller explains.

“I think the 2007 changes represent an attempt to place these codes within the correct modality section of CPT,” she says.

Codes previously listed under the “other procedures” section include a host of well-established radiology codes, says ACR. These include mammography codes—76082, 76083, 76086, 76088, 76090, 76091, 76092, 76093, 76094, 76095, 76096; many guidance codes—75998, 76003, 76005, 76006, 76355, 76360, 76362, 76370, 76393, 76394; bone studies—76020, 76040, 76061, 76062, 76065, 76066, 76070, 76071, 76075, 76076, 76077 76078, 76400; and vertebroplasty codes—76012, 76013.

Changes for 2007 include alterations involving mammography, vascular access, and cardiac computed tomography angiography, among other items.

There’s a new code for uterine fibroid embolization—37210—which covers embolization of the uterine arteries to treat uterine fibroids, leimyomata, with percutaneous approach inclusive of vascular access, vessel selection, and embolization. The code includes all of the radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the procedure.

“The new code is all-inclusive,” Miller says. “The catheter placements, embolization, supervision and interpretation, and follow-up angiograms are all covered by 37210.”

The AMA slightly altered three codes for radio frequency ablation, says Miller.

New codes for radio frequency ablation guidance include 77013 for computed tomography and 77022 for magnetic resonance. Code 76940 will still be used for ultrasound guidance.

The following mammography codes changed:

The following computer-aided detection (CAD) mammography screening codes have also changed slightly:

Business plan, debt reduction: Proper responses to DRA

With mere weeks left until the Deficit Reduction Act (DRA) implementation, radiology administrators need to prepare. Some analysts say the DRA will cost the imaging industry more than $1 billion annually.

Although many believe that something—divine intervention perhaps—will prevent the DRA implementation, “you have to behave as if this is really happening,” says Bob Maier, president of Regents Health Resources, Inc., in Brentwood, TN.

“Everyone should have done the math already,” to determine the effect of the DRA, says Fred Gaschen, MBA, CHE, executive vice president of Radiological Associates of Sacramento (CA) Medical Group.

Maier says to ask the following questions when conducting an analysis for your facility:

Strategic plans plot business success

To diversify or specify your business line, look at your surrounding market, he says. “I am amazed at the number of facilities that never completed even a basic strategic plan,” says Gaschen.

A strategic plan helps your business find its focus and earn greater profits. It uses data to accurately describe the current pitfalls and powers of your business.

For example, everyone talks about the importance of imaging to an aging baby-boom population. Examine census data in your specific area, Gaschen says. Just because the general population of elderly has increased nationwide doesn’t necessarily mean that the senior population near your facility grew as well, he says.

“The DRA makes imaging a much more competitive business,” says Maier.

Refinance debt

Centers that carry a large debt for previous facility, or equipment, improvements should look to refinance where possible, Maier says. DRA cuts could make debt repayment difficult. Should the proposed Access to Medicare Imaging Act’s two-year delay come into play, it would provide a much-needed circuit breaker for centers to refinance or renegotiate their debts. Take advantage of this, Maier and Gaschen suggest.

Renegotiate payer contracts

Further, look at contracts with payers and keep an eye on new payer regulations, says Gaschen. Many private payers have already implemented measures similar to the DRA, he says. He points to insurers United and Aetna, both of which adopted payment policies mimicking CMS’ payment reduction on same-day, contiguous body part scans. “Make sure that you’re aware of what’s going on around you in the industry so you can be prepared,” Gaschen says.

Examine commercial contracts and attempt to remove any ties to Medicare payments. Gaschen renegotiated contracts several years ago. “If you can, try to renegotiate with payers and aim for 2008. If not, you’re looking down the barrel of a double blast,” he says.

Imaging shakedown

Consolidating the market may be part of CMS’ overall design, says Maier. “Imaging centers will close [and] this can be a good thing or a bad thing,” he says.

If radiology services improve overall because of increased competition, everyone benefits. Conversely, if cuts to radiology stretch the industry too thin, then customer service suffers, he says.

“And with radiology,” adds Maier, “when we talk about customer service, we’re talking about people’s health and well-being.”

The federal government wants to reduce imaging costs, Gaschen says. “That’s correct, that’s fine. We’re talking about taking a scalpel to remove a growth. They took a meat cleaver and hacked off a leg.”

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