OIG picks radiology areas to examine

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.

• E-mail to a Colleague
• Print