Radiology Administrator’s Compliance & Reimbursement Insider, March 2007

Sometimes, the ordering physician doesn't order the most appropriate diagnostic test the first time due to a lack of understanding of recent advances in technology, Donovan-Hall says.

"They order what they think is right. But often, there are new technologies that can see more than the old tests," she says. "It's just a matter of your radiologists educating your referring physicians."

Payment problems

Many insurance companies require preauthorization for expensive diagnostic tests, such as CTs and magnetic resonance imaging (MRI).

Radiologists often take the next step of calling the treating physician and obtaining a verbal order for the test (and later documenting it in the medical record), or they write the order themselves for billing purposes.

However, payers often balk at reimbursement of the claim, Donovan-Hall says.

Although it's compliant for a hospital radiologist to perform an additional or secondary exam, "the problem lies with getting authorizations for those exams, especially the high-dollar exams," she says. "Insurance companies are really cracking down on preauthorizations." Good verifications and good scheduling are the most important things for hospitals."

Additionally, Medicare requires a specific medical necessity diagnosis for many CT and MRI exams and interventional procedures, Malm notes. If the hospital does not meet this diagnosis requirement, Medicare requires that the facility complete an advance beneficiary notice process prior to beginning the test/procedure.

"This continues to be an operational issue throughout most facilities when they add or change tests, [because] frequently the patient is already in the examination room," says Malm.

Editor's note: This article first appeared in the HCPro, Inc., publication Briefings on APCs and can be found online at www.hcpro.com/pub-116.html.

Use these four tips to improve second test payment odds

Although hospital radiologists can order additional tests and still be in compliance, insurance companies and Medicare don't always pay for these orders.

"The caveat is, will the hospital get paid for the order? That's the problem," says Christine Donovan-Hall, an independent imaging consultant in Brunswick, ME. She and William Malm, ND, RN, president of Health Revenue Integrity Services, Inc., in Cleveland, offer the following tips for health information management professionals to get paid for these tests:

1. Call the insurance company and ask for an authorization number. The problem is that this often takes 24 hours, depending on the company.

"For many of the managed Medicaid products, this can even exceed a week to complete," Malm says.

2. Instruct radiologists not to perform a second exam. Create a policy that the patient must return at a different date for a second exam, and have the ordering physician obtain a preauthorization.

For example, if the patient has a reported diagnosis that supports an abdomen-pelvis CT scan but not an abdomen CT, instruct department staff to call the patient and delay the exam for a day or so, until you can obtain preauthorization.

3. Create a verification/preauthorization specialist. Assign staff to ensure that the patient is preauthorized for the exam with the insurance company prior to establishing a date and time for the exam.

Note that many insurance products/plans require a separate authorization number for both the facility and physician components.

Consult your managed care manager and develop a matrix of what is required of each payer and plan. "This will allow the registration/scheduling staff to ensure completeness of authorization," says Malm. Many hospitals have centralized scheduling, which involves a scheduler sending the information to a preauthorization representative.

If your hospital employs this practice, Donovan-Hall recommends color-coding documents, depending on whether the patient's test requires verification.

For example, yellow claims indicate to staff that the patient's test needs preauthorization or requires other attention, whereas green indicates that the insurance company preauthorized the test.

"This makes it better for the patient because nobody wants to come in for a test and then have to return at another date for a second test," Donovan-Hall says.

4. Schedule educational sessions between radiologists and physicians. Radiologists need to update physicians to keep them informed about new diagnostic technology.

This helps physicians order the right test the first time and eliminates the need for follow-up tests, which may result in denials.

For example, a physician may order an ultrasound instead of a more appropriate CT exam.

"Physicians often don't grasp angiography exams, like CT or [magnetic resonance imaging]," Donovan-Hall says. "Many hospitals now have 16- and 64-slice CT scanners and can perform these exams, where with a single-slice CT scan, they could not."

Involve the physician billing staff in these educational sessions, suggests Malm.

"They can sometimes assist the physician in determining how this affects their private practice," he says. "Such discussions often lead to enhanced compliance and an improved revenue stream."

Compliance tops turf-battle concerns

Editor's note: This is the third in a series regarding approaches to the cardiology/radiology debate over professional ownership of heart imaging techniques and reimbursement.

Name-calling-even the best of us can revert to childhood tactics under overwhelming pressure. The cardiology/radiology fight for control over cardiac-imaging procedures pushes some professionals to just these extremes. Some even take to the Web to compare the practice of providing cardiac-imaging overreads to the oldest profession on earth.

Because cardiologists generally un-derstand the workings of the heart best, many believe they are the most qualified professionals to interpret images of the heart.

However, most imaging techniques capture information from the heart and other areas (e.g., the chest, vasculature, or lungs), which means a radiologist may be more qualified to interpret the images.

To resolve the issue, both sides be-gan performing quality assurance overreads-but who receives payment for which portion of the overread remains problematic.

Malevolent banter does nothing to resolve the complex matters surrounding the problem, but it does illustrate the base level at which the cardiac imaging fight occurs. And like all wars, the one over ownership of cardiac-imaging control essentially concerns two aspects: finances and fairness. That's where negotiation, contracts, lawyers, and laws come in.

"Everyone is trying to figure out how to make this work," said W. Kenneth Davis Jr., of the Chicago office of Katten Muchin Rosenman, LLP, during the September 27, 2006 Radiology Business Management Association Web conference "Pitfalls When Interpreting Cardiac Images: Can They Be Avoided?".

Davis suggested some of the following rules during the Web conference:

Rule #1: Stark law compliance

Depending on your point of view, governmental regulations can either help or hinder your attempts to resolve the cardiac-imaging conflict.

The Stark law essentially attempts to control physician self-referrals. It establishes the following two basic prohibitions:

Several Stark law rule exceptions do exist. The most significant to cardiac imaging remains the "in-office ancillary services" exception.

Just as there are always a few bad kids on the playground, there are some physicians who abuse the rules. Over time, some physicians started using the in-office exception to achieve higher reimbursement by owning additional imaging equipment.

Those who legitimately own scanners to provide valuable resources for their patients' health may fall into the Stark law in-office exception. Seek professional counsel to be sure.

While attempting to foster more professional relationships between cardiologists and radiologists, make sure to document the terms of the relationship in writing and in compliance with the Stark law personal services exception, Davis said.

Key provisions of the agreement should address the following questions:

Rule #2: Play fair

The most important principle, for compliance purposes, under the federal anti-kickback statute and Stark law (as well as many other state laws) is whether the amount you pay represents fair market value.

When developing financial agreements for imaging interpretations between radiologists and cardiologists, determining fair market value for the actual work accomplished is vital to the arrangement's success.

"Neither a radiology group nor a cardiology group should enter into an arrangement if the compensation is not fair market value," said Davis.

The concern is most acute with respect to any amounts cardiologists receive for making referrals to the radiologists and hospital.

Tip: Look for a principled way to help both parties determine and document fair market value. Do this through cost benchmarking in your area. Have both sides pick apart the exam and interpretation process and establish a rational approach to allocating the percentage of reimbursement for the interpretations. "And it shouldn't turn into 'I'm the radiologist [or I'm the cardiologist], so I get the big money!' " Davis said.

Rule #3: Follow the False Claims Act

The federal False Claims Act imposes civil and, in some cases, criminal liability on organizations and individuals who make fraudulent claims to the government.

The false or fraudulent claim may be intentional, or it may be due to reckless disregard for the accuracy of the claim.

Reporting false claims represents a legitimate concern in cardiac-imaging procedures at this point, particularly as it relates to cardiac CT (CCT).

For example, if a cardiologist reads the heart portion of the CT exam but relies on the radiologist to read the chest portion of the exam, neither side could report a complete CCT scan without concerns of reporting a false claim.

The eventual resolution of assigning more accurate codes and code descriptions for cardiac imaging procedures across the board could "go a long way to resolving the compliance issues, provided cardiologists become comfortable reading any nonheart portions that still have to be read," Davis said.

Reporting shared interpretation in every other field offers similar difficulties, and cardiac imaging is no different, Davis said.

Healthcare facilities often arrange some type of third-party overview or supplemental reading when dealing with rereading, subspecialty groups, or for quality assurance reasons, Davis said.

Medicare and other payers take notice if facilities bill for such services twice, or they receive a bill for additional charges, he said.

To reduce the likelihood of being accused of filing a false claim, make sure that no additional charges result from the additional readings.

Davis allegorically refers to one Medicare carrier's answer to the shared read legality question.

The carrier asked the following questions:

Under such circumstances, this carrier said it would give its okay.

To better ensure a clean claim, Davis recommended that you do the following:

Feel free to ask your local carrier for clarification regarding specific practices or claims, but be careful. (Imagine asking the teacher for clarification about those playground rules: "Um, Mrs. Jones, is it not okay to push little Jimmy on the pavement?")

Determine the risk involved in the resulting answer-you likely won't know for certain what the answer is going to be-and make sure that you plan for potential mitigation. "It's always risky, but asking the Medicare carrier directly may be your best approach to address the false claims concerns," said Davis.

Overall, when attempting to resolve the cardiac imaging turf war between cardiology and radiology professionals, the best advice may already exist within accessible rules.

Don't let emotions regarding reimbursement and ownership turn a rational discussion into a schoolyard scuffle, Davis said.

Insider source

W. Kenneth Davis Jr., JD, Katten Muchin Rosenman, LLP, 525 West Monroe Street, Chicago, IL 60661-3693, 312/902-5573; Ken.davis@kattenlaw. com.

Fair market talking points

Consider the following items when sitting down for fair market value discussions:

1. Payment to cardiologists for quality assurance overreads must not exceed fair market value

2. The amounts cardiologists retain must not exceed fair market value after paying radiologists for quality assurance overreads for interpretations by the radiologists of the nonheart portion of studies

3. Conversely, radiologists cannot accept less than fair market value for quality assurance overreads or for interpreting the nonheart portion of studies

4. If the billing physician interprets the entire study, he or she should receive all of the professional component compensation

5. However, in the previous case, the billing physician still should be able to pay fair market value compensation to the nonbilling physician for quality assurance overreads

6. If the billing and nonbilling physicians share the responsibilities for providing the interpretation (assuming its legal in the first instance to do so), they'll need to determine, document, and defend fair market value for each interpretation

Coding corner

Dealing with docs: Tips and tricks to ensure physician assistance with coding and documentation compliance

The perceived overuse of diagnostic imaging has become the focus of increased payer and government scrutiny. That makes raising physician awareness and assistance in submitting appropriate documentation more important than ever.

"Too often, doctors are so focused on patient care they sometimes forget to focus on coding and documentation. But if they do not, they won't get paid for the work they do," says Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, vice president of Southeast Radiology Management in Stuart, FL.

Some physicians think documentation takes time away from patient care and that compliant coding reflects nothing about the quality of attention patients receive.

"These statements are just not true," says Stacy Gregory, RCC, CPC, president of Gregory Medical Consulting Services, in Tacoma, WA. "Good documentation is critically important to patient care."

Lessons for physician learning

Physicians typically have a limited understanding of the fiscal world in which they operate, according to Gregory.

For example, medical school teaches physicians how to scan the breast in search of potential lesions, but not about the difficulties of obtaining payment for the procedure.

Make educating physicians about documentation and coding a priority. Explain documentation guidelines according to both the American Medical Association's Current Procedural Terminology book and the American College of Radiology, she says.

Regardless of their profession, certain people show particular interests in specific subjects. Find one person who pays more attention to the documentation and foster a positive relationship with him or her.

Express your appreciation for his or her documentation skills and attention to detail. Then, encourage that person to share such knowledge with colleagues. Make this person your physician champion to assist in physician education. "Physicians are more likely to consider messages coming from another physician," says Buck.

Make sure to differentiate between the type of language physicians use and the type of language you, as an administrator, manager, or coder, use on a day-to-day basis. "Doctors don't understand code-speak," says Gregory. Clinical-speak and code-speak do not necessarily go hand-in-hand."

Recruit someone from your coding department as a physician liaison, as well. Put that person in charge of communicating with physicians, sharing local coverage determinations, and payer developments.

This liaison should explain to physicians how documentation helps coders distinguish between procedures, and how such distinctions sometimes reflect big dollar amounts, says Buck.

Tips for talking

You don't need to associate dealing with physicians with that awkward annual Thanksgiving conversation with your Aunt Edna. A few simple solutions can make physician/administrator exchanges effortless.

Pay attention to the first rule of thumb-don't be intimidated by physicians, says Buck. Be assertive, but not aggressive. Look them in the eye, remain calm, and behave appropriately, she says.

In addition, offer physicians an opportunity to speak privately about any documentation concerns you have.

Identify and address documentation errors right away, says Buck.

Timely discussions with physicians facilitate correct claims on the front end. They also instill a sense of urgency and importance. Frank conversations diffuse tension buildups and eliminate opportunities for additional errors.

Conversely, cornering a physician to discuss documentation when he or she happens to walk by establishes a confrontational atmosphere, says Gregory. By inviting physicians to cooperatively discuss claims concerns, you offer them a modicum of discretion, convenience, and an opportunity for investment in potential problem resolutions.

For example, ask for suggestions to ease their documentation burden. This may come in the shape of a form or online tool, Buck says.

Action advice

It's a truism-some people just don't get it. Some physicians won't either. You tried talking with them and using friendly reminders and straightforward discussions, but still that one physician persists in improper documentation practices.

Begin exploring disciplinary options. Create an improvement tool-a form to document and track areas of concern, says Buck.

Submit the form to a disciplinary committee member, such as the medical director, chief radiologist, or your physician champion, for review and possible resolution.

Depending on your status within the facility or hospital setting, you may or may not have the "power" to do this, Buck says. "Administrators must provide support and enforcement for your efforts."

Insider sources

Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, vice president, South-east Radiology Management, 512 SW St. Lucie Crescent, Stuart, FL 34994, 772/600-0324; stacie@southeastrad.com; www.seradmgt.com.

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

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