Radiology Administrator's Compliance & Reimbursement Insider, May 2007

“Your willingness to partner with the carrier’s medical director and his or her committee could be your secret weapon to front-end denials management,” Davies explains.

Editor’s note: Kelly Davies and Mark Canada presentedthis information during HCPro, Inc.’s February 15 audioconference “Tracking and preventing radiology denials: Tools to ensure appropriate reimbursement.” For more information, visit www.hcmarketplace.com/ prod-5009.html.

Insider sources

Mark Canada, MHA, CPC, regional vice president, Medical Practice Management, Inc., 5711 Chamberlayne Road, Richmond, VA 23227, 804/262-6900, Ext. 136; mcanada@medpmgmt.com.

Kelly Davies, director of operations, CBIZ Medical Management Professionals, 6501 Deane Hill Drive, Knoxville, TN 37919, 865/766-8800; kdavies@medmanpro.com.

Cool cardiac imaging conflicts with contract know how

Editor’s note: This is the fifth in a series about approaches to the cardiology-radiology debate over professional ownership of heart imaging techniques and reimbursement.

One resolution to the cardiology/ radiology turf war lies in contract negotiations between the physician groups and the hospital.

Radiology administrators may play a major or a minor role in guiding physicians and hospital higher-ups, depending on their sphere of influence and professional obligations.

By simply understanding the benefits and detriments of these agreements on the department and the physicians attempting to use them, administrators may help ease the conflict—and their own turf war battle fatigue.

Not-so-exclusive agreements

Many hospital-based radiology practices have “exclusive” agreements with hospitals for radiology services.

But exclusive agreements don’t automatically give radiologists the right to read every exam.

Instead, “exclusive” may mean that one radiology practice is the only radiology practice allowed to work at that particular hospital.

It may not mean it is the only specialty allowed to interpret radiological tests, says Michael Schaff, JD, attorney and chair of the healthcare team at Wilentz Goldman & Spitzer, PA, in Woodbridge, NJ.

“Hospital-based radiology practices should negotiate in their contracts a broad exclusivity provision that focuses on the services they provide,” says Schaff.

For example, if your hospital plans on becoming the premiere heart care center in your area, you’ll want to help both sides focus on the needs of those clients and your radiology department services.

Options for contracts

Essentially, two choices exist for exam ownership. Physicians can try to use their influence to obtain an exclusive right to perform those services, or they can share the pie, Schaff says.

For hospital management, both of these resolutions represent workable opportunities.

Shared responsibility contracts allow two physicians to split the professional fee by using a modifier to denote shared responsibility.

Or, the radiologist can agree to overread the cardiologist’s interpretation for a fair market value fee that the cardiologist pays to the radiologist, or vice versa.

“Many radiologists see shared contracts as an opportunity for other subspecialties to grab a share of radiology,” explains healthcare attorney W. Kenneth Davis Jr., JD, partner at Katten Muchin Rosenman LLP, in Chicago. “Radiologists worry that this kind of shared agreement may set a precedent—if they let cardiologists read, then the neurologists will want to read, too.”

Choice evaluation

Make sure to assess all the pros and cons of both arrangements prior to encouraging either exclusive or shared contract choices with hospital management, Schaff says.

Talk to your facility attorney, gather more information about potential arrangements, and consider the following items first:

Review the following potential detriments to such agreements prior to throwing your support one way or the other:

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

Michael Schaff, JD, Wilentz Goldman & Spitzer, 90 Woodbridge Center Drive, Suite 900, Woodbridge, NJ 07095; schafm@wilentz.com.

Exclusivity contracts can help navigate turf war trouble

Present the following sample contracts to your radiologists as discussion points toward resolving cardiac imaging ownership disputes.

Make sure to have your attorney examine the language beforehand to suit your specific needs.

Exclusive right sample contract

a. Hospital engages XYZ Radiology to perform and bill for all professional radiology services performed in hospital, and agrees that, pursuant to this agreement, XYZ Radiology shall have the exclusive right to perform and bill for such services.

b.“Professional radiology services” is defined as: (List services by name and/or CPT/HCPCS code).

c. This agreement set forth in this clause shall be for a term of 36 months, renewable automatically, provided that either party may terminate this agreement upon 12 months’ written notice.

d. From time to time, the parties may, by mutual agreement, add or delete services from subparagraph (b).

Shared responsibility sample contract

a. The parties agree that responsibility for providing certain cardiac imaging services enumerated in subparagraph (b) hereof will be shared among the members of the cardiology department and the radiology department.

b. The following cardiac imaging services are subject to this agreement: (List services by name and/or CPT/HCPCS code).

c. One member of each department shall interpret and submit a written interpretation of each test described in subparagraph (b) hereof within 24 hours of its performance. If a member of one department fails to interpret the test within the 24-hour period, the member of the department who has interpreted the test may assume the sole responsibility for interpreting the test and the sole right to bill for the service.

d. Interpreting physicians may each bill for an interpretation using the appropriate modifier indicating that responsibility for the service was shared. Parties agree that all coding and billing for the procedures subject to this agreement will be handled in accordance with all applicable laws, rules, and regulations.

e. The agreement set forth in this clause shall be for a term of one year, and shall renew automatically unless one party gives 30 days’ written notice of a desire to amend or terminate this agreement.

Editor’s note: Find this and other helpful contract information in HCPro, Inc.’s The Radiology Manager’s Handbook: Tools and Best Practices for Business Success. To learn more, visit www.hcmarketplace.com/prod-186.html.

Proposed Medicare membership rules nixed

Implications of axed language remain

Imagine hiring only full-time radiology technologists. Picture a consistent, dedicated radiologist at your facility. Think about not needing to share time on the MRI, or share a central waiting room with another practice. It’s just what CMS hoped to require in its Medicare Program Integrity Manual Transmittal 187, released January 26, relating to independent diagnostic testing facilities’ (IDTF) enrollment in Medicare.

All these items may sound terrific, but the reality of life at IDTFs isn’t that dreamy. Some of these items represent the necessary realities of day-to-day business in radiology, but federal healthcare officials didn’t quite see it the same way.

Where’d that come from?

The proposed changes for IDTFs originally appeared in the Medicare Physician Fee Schedule final rule, according to a release from the American College of Radiology (ACR). And, initially, they represented little concern for the imaging industry. But Medicare later amended the requirements adding further restrictions on IDTFs in the transmittal. “The additional language added by CMS to this transmittal, which was to have been implemented in an unusually short 30-day timeframe, appeared to exceed CMS’ authority,” the ACR release states.

“The language in the transmittal was where the rubber hit the road. These were potentially disruptive situations,” says Wayne Blank, cochair for public policy for the National Coalition for Quality in Diagnostic Imaging Services in Houston, TX, which lobbied the agency to rescind its IDTF requirements. “They took the language to a new level, reaching far beyond what the IDTF standards as initially published in December 2006.”

They wanted to do what?

CMS included other requirements, too, says Thomas W. Greeson, Esq., of Reed Smith, LLP, in Falls Church, VA. Greeson summarized additional transmittal highlights that could ultimately affect imaging in the future—which could adversely affect IDTFs—including the following:

Now what are we going to do?

Blank says CMS simply wasn’t aware of the implications behind the new requirements.

Quick conversations between the government agency and imaging association representatives reversed the requirements in February.

However, the language—and the intent behind it—continues to echo like a bad nightmare.

“Essentially, at the heart of the matter, CMS seems to be trying to address quality concerns, and fraud and abuse standards,” says Blank. “While it may have been well-intentioned, it didn’t translate in a practical sense to the imaging industry.”

Medicare officials listened carefully to the objections of the imaging industry and worked with a variety of officials before ultimately eliminating the new requirements, Blank says. If radiology administrators think they can breathe easier, a rude awakening may be in their future. “These underlying concerns aren’t going away,” says Blank. We have to address this ourselves, as an industry. It doesn’t do any of us any good if there are bad players out there.”

Insider sources

Wayne Blank, cochair for public policy, National Coalition for Quality Diagnostic Imaging Services, 1501 Malone, Houston, TX 77007, 877/864-5400; wblank@medquestmail.com.

Thomas W. Greeson, Esq., Reed Smith, LLP, 3110 Fairview Park Drive, #1400, Falls Church, VA 22042-4536, 703/641-4242; tgreeson@reedsmith.com.

Imaging update

Moratorium, not delay, proposed for the DRA

Congress reintroduced the Access to Medicare Imaging Act (AMI) (HR1293) on March 1. The initial proposal, brought forward in August 2006, proposed to pause the negative effects to the imaging industry of the Deficit Reduction Act of 2005 (DRA).

The latest version seeks a two-year freeze on the related reimbursement reductions. A contentious congressional election and imaging lobbyists’ late start led to the demise of the 2006 AMI in December.

“In essence, it’s the same bill,” says American College of Radiology’s (ACR) Senior Director of Government Relations Josh Cooper. “But we needed to work with our new congressional counterparts, line up new supporters, and deal with the details of the language of the bill.”

Determining DRA’s detriment

The DRA caps the technical component reimbursement for physician office imaging to the lesser payment of the hospital outpatient prospective payment system or Medicare fee schedule payment. In addition, the law cuts technical component payments for scans performed on contiguous body parts.

“The DRA was a total public policy disaster,” said Cindy Moran,assistant executive director of government relations for the ACR, during the February 5 GE Healthcare Webcast, “Facing the DRA together.”

Some see cuts as an effort to curb overuse of expensive radiological exams by making it more difficult for non-radiologists to perform imaging exams.

Prognosticating future reimbursement

A report by the Moran Company, located in Arlington, VA, released by the Access to Medical Imaging Coalition, anticipates a drop in freestanding facility payments to 18% below total reimbursement for similar services in hospital departments. Further, center directors should expect less-than-adequate funding for 89% of cut procedures.

“With the 2007 version of AMI, industry leaders hope for “a more positive solution to imaging reimbursement problems,” Cooper says. How the AMI proposal plays out over the coming legislative year remains anyone’s guess, he adds. The bill might morph into a larger Medicare overhaul scheme, or pick up amendments along the way.

“We’re in a good place to make the case that the DRA was a mistake from many different vantage points,” he says. “Nevertheless, it’s going to be a nail-biter again.”

Insider sources

Josh Cooper, American College of Radiology, senior director of government relations, 1891 Preston White Dr, Reston, VA 20191, 703/648-8900; jcooper@acr.org.

Cindy Moran, American College of Radiology, assistant executive director of government relations, 1891 Preston White Drive, Reston, VA 20191, 703/648-8982; cmoran@acr.org.

AMI action items on the Web

Imaging officials encourage grassroots efforts by imaging center administrators and other radiology professionals in dealing with the Access to Medicare Imaging Act of 2007 and the law it’s meant to mitigate—the Deficit Reduction Act of 2005.

To learn more about what you can do, visit the following Web sites:

Coding corner

What a difference calcium scoring makes to payers

Medical necessity guidelines for cardiac computed tomographic angiography (CCTA) procedures vary widely among payers with universal exclusion for asymptomatic patients.

Three particular codes—0144T, 0146T, and 0147T—represent nothing but trouble for hospitals and imaging centers alike, due to perspectives on calcium scoring.

“A couple of carriers say they are not paying for calcium scoring of CCTAs,” says Jim Collins, CPC, ACS-CA, CHCC, president of The Cardiology Coalition in Matthews, NC. “They say it’s tainted fruit.”

The American Medical Association adopted a number of new codes in the 2007 CPT Manual to describe various common scan combinations used for cardiac computed tomography (CCT) and CCTA studies.

As with all Category III (new) codes, the CCTA codes caused some dismay, but the concern with calcium scoring offers its own snags.

That’s because three of the new codes contain some form of calcium scoring within their description, says John Marshall CRA, RCC, RT®, prospective payment coordinator for interventional vascular and radiology at Sarasota (FL) Memorial Healthcare System.

Most payers do not cover coronary calcium scoring, says Marshall. “Medicare and most payers consider calcium scoring (0144T) to be a screening test. However, many payers have applied this rationale to the other CCTA studies because they include minor calcium scoring components within the relatively extensive CCTA procedure. But this is the ultimate moving target. It varies by payer, by region, and seemingly, by day of the week.”

Payers don’t want to reimburse for these screening exams, agrees Melody W. Mulaik, MSHS, CPC, CPC-H, RCC, copresident of Coding Strategies, Inc., in Powder Springs, GA. “A true screening means there are no signs/symptoms, and payers see that as an awfully expensive test for someone with no signs/symptoms of heart disease. They don’t want physicians ordering CT scans of the coronary arteries when the real intent is the calcium scoring,” she says.

Stick to the rules

Calcium scoring helps detect the amount and potential effect of coronary artery disease early.

CCTA is not a covered service for asymptomatic patients. Additionally, three of the new Category III codes contain a calcium scoring component that CMS has classified as a ‘screening exam,’ Marshall says.

Resolve calcium scoring confusion

Despite payers’ hesitancy to come through on reimbursement for calcium scoring, physicians—both cardiologists and radiologists—agree that the scoring element remains critical for “with contrast” scans to adjust images and remove false positive findings, says Collins.

Even though CMS approved calcium scoring as a component of some of the CCTA exams in its draft local coverage determination template, says Marshall, “most payers adopted three of the diagnostic exams but excluded reimbursement of the other two exams because they include a relatively minor calcium quantification [scoring] component.”

The confusion could spur a “big negative effect,” Collins says, particularly if physicians stop performing the scoring portion of the exam, document their work inaccurately, or if coders improperly assign the new codes.

Category III temporary codes help tell the healthcare industry who uses what procedures and why. Inappropriate use of these codes leads to collection of inaccurate data and further billing and coding problems down the line, says Collins.

That’s why it’s vital for everyone to become familiar, not just with the new code definitions, but with the multiple requirements of various payers, says Collins. Examine individual payer newsletters. And when you can’t find the information, call and ask. It may seem overly simplistic, but sometimes the best route is the most direct route.

“A clear understanding of payer guidelines [coverage and coding] is critical to materializing income projections,” Collins says. “If payer guidelines are not favorable, they should be appealed.”

Editor’s note: Learn more about cardiac imaging coding and reimbursement challenges in the recently released HCPro, Inc., publication Cardiac Imaging: Strategies for Appropriate Documentation and Compliant Coding, available at www.hcmarketplace.com/prod-5008.html.

Insider sources

Jim Collins, CPC, ACS-CA, CHCC, president, The Cardiology Coalition, 4812 Hickory Lake Lane, Matthews, NC 28105, 704/845-5142; jim@cardiologycoalition.com.

John Marshall CRA, RCC, RT®, prospective payment coordinator, Sarasota Memorial Healthcare System, 2433 Huntington Avenue, Sarasota, FL 34232, 941/716-5657; John-Marshall@smh.com.

Melody W. Mulaik, MSHS, CPC, CPC-H, RCC, copresident, Coding Strategies, Inc., 5041 Dallas Hwy, Suite 606, Powder Springs, GA 30127, 877/626-3464; Melody.Mulaik@CodingStrategies.com.

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