Radiology Administrator's Compliance & Reimbursement Insider, July 2007

Those contemplating such agreements, however, must consider potential anti-kickback violations.

"The anti-kickback statute is strict," says Leora F. Ardizzone, Esq., an attorney with Ruskin Moscou Fal tischek, PC, in Uniondale, NY. "Any remuneration can be considered an inducement to refer" and a violation of the statute, she says.

A no-win situation

Ardizzone represents a variety of clients on all sides of the complex equation. On the one hand, she says, referring physicians and their office staff juggle enough responsibilities. However, insurers need to ensure medical necessity for expensive imaging exams.

Under this logic, the referring physician understands his or her patients' medical needs best. Therefore, it seems to make the most sense for the referring physician to complete the appropriate paperwork-just not the most fiscal sense. "The referring physician doesn't benefit from this extra work, work which translates into employee time and practice money," says Ardizzone.

On the other hand, when patients enter the radiology department/imaging center, they enter with the expec tation of obtaining an exam. If a patient arrives without a preauthorization, only three options remain for the radiology facility-turn the patient away, perform the exam and risk payment denial, or obtain the precertification for the patient in the imaging facility.

The first two options offer less than opportune business practice. Turning patients away won't earn your department or facility any more business. And performing an expensive exam that may or may not be reimbursed could cost big bucks. So, says Ardizzone, many facilities accept the anti-kickback risk and offer to obtain precertifications for referring physicians.

"From their perspective they're trying to do the best thing for referral sources and for the patients who need these exams," she says.

Creative, but inappropriate, solutions

Ardizzone relates the parameters of the Stark Law and federal anti-kickback statute to her clients, but some persevere with creative solutions to the precertification problem. For example, one radiology facility considered placing one of its own staff members in the referring physician's office. For a set time each week that person would help the physician's office fill out the needed precertification forms. Even this, says Ardizzone, represents a breach of the anti-kickback law.

"The location of the individual doesn't matter," she says. "If you trained them, and if your facility pays their salary, then this could be considered remuneration, or an incentive for that referring physician to send you his or her clients."

Further, if one radiology department/imaging center offers such services, it creates an unfair business advantage, forcing others to offer such services, too.

So some radiology managers "take the calculated risk," Ardizzone says. "They think, 'I don't see the anti-kickback police walking around here.' Well, maybe not, but insurance investigators, claims auditors, and whistle-blowers are everywhere."

Calculated, but expensive, risk

Those offering precertification assistance don't think they're doing anything wrong, and they believe they're helping everyone out, says Ardizzone. "They don't think this is such a big nut," she says. But under the anti-kickback statute, any remuneration counts as a violation.

And violations of the law come with steep penalties. An insurer may threaten to terminate a provider agreement with a facility or practice that attempts to thwart precertification protocols. Additional penalties include:

Some believe anti-kickback violations don't carry as much weight as the current precertification burden. But don't fall prey to such thinking, says Ardizzone.

"The pressure to get patients in is so great that some risk potential violations to anti-kickback," she says. "Beware: If you get terminated by a major payer or prosecuted for violating federal law, you may lose more than you stood to lose if you just said 'no.' "

Insider source

Leora F. Ardizzone, Esq., Ruskin Moscou Faltischek, PC, 15th Floor, East Tower, 1425 RexCorp Plaza, Uniondale, NY 11556-1425, 516/663-6520; Lardizzone@rmfpc.com.

Coding corner

New angioplasty-of-dialysis fistula/graft codes cause dismay

by Jackie Miller, RHIA, CPC

Arteriovenous (AV) grafts and fistulas provide long-term access for hemodialysis in patients with end-stage renal disease. Interventional radiologists frequently treat complications of grafts and fistulas, including thrombosis and stenosis. Coding for angioplasty of dialysis fistulas and grafts became more complicated in 2007 when CMS implemented new Healthcare Common Procedure Cod ing System codes for these procedures.

Apply codes G0392 and G0393 for Medicare payment under the hospital outpatient prospective payment system, as well as the physician fee schedule. The new codes apply regardless of imaging setting.

In addition to the G code, report the radiological supervision and interpretation of the angioplasty with CPT codes 75978 (venous angioplasty) or 75962 (arterial angioplasty).

Pay attention to separately reportable items

Be careful to report angioplasty once for each vessel treated. For coding purposes, define an AV graft or fistula as a single vessel beginning at the arterial anastomosis and extending through the body of the graft, the venous anastomosis, and the outflow vein. All of these structures are part of the fistula or graft, so code only one angioplasty regardless of the number of stenoses treated within the area.

However, angioplasty of a central vein is separately reportable. This includes, for example, AV fistulas or grafts in the arm, subclavian vein, and/or brachiocephalic vein.

So when angioplasty is performed in the AV fistula or graft, and also in a central vein, code for two angioplasties.

For coding purposes, consider the entire fistula or graft as a vein. When the physician performs an angioplasty of the arterial anastomosis along with angioplasty of the body of the graft, the venous anastomosis, and/or the outflow vein, code for only one venous angioplasty. Depending on payer policy, it may be appropriate to report an arterial angioplasty if the arterial anastomosis represents the only area treated.

Use these cases to practice appropriate coding

These examples of appropriate code assignment for angioplasty of AV fistulas and grafts can help comprehension. If the payer does not accept G codes, you should report the corresponding CPT code:

Codes: G0393, 75978

Note: Code only one angioplasty. because the axillary vein is considered part of the AV fistula or graft

Codes: G0393, 75978

Note: Treat this as an angioplasty of a single vein

Codes: G0392, 75962

Note: You can report treatment of the arterial anastomosis alone as an arterial angioplasty, if payer policy permits

Codes: G0393, 75978, 35476, 75978

Note: When the physician treats both the graft/fistula and a central vein, report two angioplasties

With careful attention to coding guidelines, coders will soon learn how many-and what type of-angioplasties to report in these AV fistula/graft cases.

Editor's note: Miller is a senior consultant for Coding Strategies, Inc., in Powder Springs, GA. Contact her at Jackie.Miller@CodingStrategies.com.

Case study

Communication crucial to resolving imaging fracas

Editor's note: This is the final installment in our series regarding best practices and practical approaches to resolving the cardiology/radiology debate over professional ownership of heart-imaging techniques and reimbursement.

Joint venturing, contract negotiations, split reads- radiology administrators face a variety of options for handling turf war trouble between cardiologists and radiologists.

For Brook Ward, executive director of clinical and ambulatory services for Bronson Healthcare Group in Kalamazoo, MI, the secret to implementing a successful cardiac-imaging program included all of these items. But the success relied on one more aspect-communication.

Bronson begins resolution with basic discussions

Conversations with both cardiologists and radiologists began in the research phases for Bronson's new CT scanner. "We didn't want to wait until the machine was here to figure out what we were going to do with it," he says.

Use of CT machines for cardiac imaging began as a trickle, Ward says. But as clinical experience with the scan grows, so does its use. "We're seeing a big deluge of hospitals purchasing, or thinking about purchasing, these machines now," he says.

Group starts conversations between parties

Ward investigated several potential pitfalls and possible opportunities when considering the purchase of a new CT scanner. He asked himself the following questions and brought his queries to the physician groups to foster communication:

Radiologists understood the implications of the cardiac-imaging technology, Ward learned. But as it turned out, at least one Bronson-associated cardiology group opted out of cardiac CT talks altogether. "They just weren't interested," Ward says.

Contractual traps stall progress

At Bronson, radiologists already maintained an exclusive contract that gave them rights to perform imaging procedures, Ward says.

So if Bronson planned to include cardiologists performing cardiac-imaging procedures using its new CT machine, it had to renegotiate radiologists' exclu-sive contracts and draw up new contracts with the cardiologists.

That took conversation-and lots of it, he says. "I have to say that communication was the key for us," Ward says.

Cardiologists and radiologists at Bronson discussed operating under a joint venture contract, with half the procedure going to the radiologists and half benefiting the cardiologists.

"This is an area that is rife with legal land mines," said Todd Sagin, MD, JD, vice president and national medical director of The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, who spoke during HCPro's audioconference "The 64-Slice CT Scanner: The latest battleground in specialty turf disputes" (www.hcmarketplace.com/prod-4874.html).

Regardless of which approach your facility picks-joint-readings, overreads, or alternate billing arrangements-be sure to "establish a clear legal basis for it, because the false claims act, antitrust concerns, and Stark violations all have an impact on some of the schemes out there," Sagin said.

"We don't know how the government will view them in the future," he said.

Joint venture worries force further discussions

Although the joint venture option seemed to excite both sides at Bronson, "it just didn't work out legally for our particular situation," Ward says.

Through numerous discussions, Bronson officials finally helped facilitate an agreement in which radiologists retained their exclusive contract with the hospital but subcontracted additional interpretations to the cardiologist practice. The radiologists get paid, and they pay the cardiologists, Ward says.

"No matter what you chose to do, you need to keep an eye on the legal department and work closely with it, so if something changes [legally], you won't be on the hook [and in violation]," says Ward.

In the end, the hospital radiology administrator acts as a facilitator of the relationship. As such, he or she keeps the teamwork rolling while fostering dialogue and collaboration to establish a winning situation for all.

Henry Ford unearths a way to harmony

Some institutions find themselves in better collaborative positions than others. That's the case at the Henry Ford Hospital in Detroit, says Radiology Administrator Cheryl Martin.

Henry Ford's long academic history of working across departments and specialties helped reveal opportunities for continued relationships when it came to implementation of cardiac-imaging protocols, she says.

"Our physicians work as a group, so the determination of patient management is based on a team ap proach," Martin says.

A collaborative approach is ideal for several reasons, says Timothy Albert, MD, cardiologist at Central Coast Cardiology in Salinas, CA. "In general, most hospitals don't have a [cardiac-imaging] specialist. That represents an opportunity for both sides to bring something to the table," he says.

Henry Ford maintains a joint cost center where it pours all revenue from cardiac-imaging procedures into one account and divides it according to fair market value to both services, says Martin. "When performing joint readings, the cardiologists get the heart portion, and the radiologists get the rest," she says. Henry Ford files a single bill with a modifier -59 to signify a distinct procedural service, remaining careful not to bill twice for the same procedures.

That doesn't mean Martin established cardiac-imaging programs without turf war trouble. She simply managed them by communicating early and often, she says, to keep parties from fighting over procedures."I'm here to tell you that turf wars are real," says Martin. "Everyone has certain items they need to work out. Without open dialogue, how will you ever be able to surpass that conflict and work for the best interest of the patient?"

Credentialing charts pathway to peace

One primary discussion circled around maintaining an appropriate knowledge base to perform these complicated cardiac-imaging scans, says Martin. That meant establishing criteria for privileging and credentialing standards for performing cardiac-imaging scans.

She suggests that radiology administrators talk to vested parties and facilitate the following steps:

1. Establish a cardiac-imaging credentialing policy

2. Obtain recommendations from medical staff members and interested parties

3. Research association suggestions (e.g., American Col lege of Radiology, American Association of Cardiology, etc.)

4. Establish an agreement between the parties

5. Propose the agreement to the privileging committee

"It worked here because of communication," Martin says. "Keep going back to what's in the best interest of the patients."

Insider sources

Cheryl Martin, radiology administrator, Henry Ford Hospital, Detroit, MI.

Todd Sagin, MD, JD, vice president and national medical director, The Greeley Company, 200 Hoods Lane, Marblehead, MA, 01945, 781/639-1872; tsagin@greeley.com.

Brook Ward, executive director of clinical and ambulatory services, Bronson Healthcare Group, One Healthcare Plaza, Box C, Kalamazoo, MI 49007-5341, 269/341-8102; wardb@bronsonhg.org.

Budget building blocks

Tips to create financial foundation for your imaging facility

Face it. Some of us would rather lose a tooth than sit down to develop the annual department budget. But procrastination often leads to more detrimental losses than those most often felt in the dentist chair.

If the budget process intimidates you, you're not alone, said David Sack, radiology director at Stamford (CT) Hospital. Sack discussed budgetary basics in his presentation "Winning the Jackpot: The Keys to Budget Creation, Review, and Defense," during the 2006 Amer i can Healthcare Radiology Administrator's annual meeting in Las Vegas. (The next meeting takes place in Orlando, FL, July 8-12; visit www.ahraonline.org for information.)

Many radiology administrators such as yourself worked their way into a management position after years in the trenches.

So although many department leaders perhaps didn't major in radiology business management, they still must create that annual budget and present their fiscal prowess to upper management.

"The annual budget process is vital for your success in your position," Sack said. "It allows you to prioritize initiatives and strategies, and provides a method to measure overall performance against established goals. That's something everyone can understand."

The numbers drill

Creating a budget requires an enormous time commitment. First, you must sort through the various pieces of the budgetary puzzle. Historical data and previous accounting often offer misleading, inaccurate, or just plain confusing data.

Further, earlier radiology fiscal wizards might have placed items in strange cost centers or used complicated terms to describe topics no more complicated than your budget at home. For example, Jason Newmark, operations manager for Stamford Hospital's ambulatory radiology facilities, discovered a $2,400 line item labeled "purchased services," which he eventually learned paid for regular cleaning of the offices' aquarium.

Combine all of these difficulties with a general fear of fiscal management, and compiling the annual budget starts to feel like the Novocain might be wearing off.

"People, in general, are afraid to make mistakes. They're afraid to ask for help because it could show some sign of weakness," Sack said.

Conversely, those in charge of your hospital's fiscal management don't necessarily understand radiology either, he said. "That's why it's so important for radiology administrators to understand the budget process."

A budget bit

The annual budget allows you to prioritize initiatives and strategies. Need to improve patient-flow but need additional staff members to do so? The annual budget helps you make that case to the hospital higher-ups. Further, it offers you options to measure overall performance against the goals you establish.

"The budget process is vital for your success. It enables you to step back and look at the big picture," said Sack.

People formulate a budget in a variety of ways. Some use an annualized budget to forecast their expenses, others develop a fixed, or flexed, budget. Still others operate from zero-based budgeting (see "Budget terminology" below).

All options represent appropriate accounting tactics, but each offers a unique focus-a focus that may or may not work out well for your department in the long run.

Labor: The biggest bite

Every radiology administrator, like every business manager, knows his or her greatest annual expense stems from labor costs. At Stamford Hospital, Newmark uses a spreadsheet to break down full-time staffing expenses:

Every department maintains a set number of non-productive hours for sick time, vacation days, personal days, and so forth, Newmark explained. So be sure to factor that in to the whole budget process.

"You have to make the administration understand that this part of the budget is purely bodies to cover minimally what the hospital currently provides as services," said Newmark. When an administrator or hospital plans expanded services, it comes with expanded staffing obligations, he said.

Understand the department's workflow

Take the time to understand the department's workflow, Newmark said. Every piece of equipment and every room operates at a particular capacity. "You can't be booked 100% of the time," he said.

So be realistic when creating a labor budget and ac curately represent the amount of time and staff it takes to complete each procedure.

With a full understanding of existing staff and performance conditions, you can better argue your overall departmental needs to the hospital/facility chief financial officer by projecting future staff needs. Take the time to model your plans for department growth both in modality use and in the staffing level it takes to manage that growth, Newmark said.

Developing a staff budget won't seem like subclavial surgery if you seek assistance from employees. Get them involved, said Newmark.

Staff members hold much of the process and hands-on information you need to formulate this year's annual budget, discover the previous year's pitfalls, and plan for future development.

Insider sources

David Sack, radiology director, Stamford Hospital, 30 Shelburne Road, Stamford, CT 06904; dsack@stamhealth.org.

Jason Newmark, operations manager, Stamford Hospital, 30 Shelburne Road, Stamford, CT 06904; jnewmark@stamhealth.org.

Budget terminology

Fixed: In this type of budget process, the amount budgeted equals the amount spent. A fixed budget does not account for possible changes in business activity. Such a budget works well for those without changing costs and without alternating incomes. Otherwise, a fixed budget tends toward inaccuracy over time.

Flexed: Your radiology department budget calls for the performance of a certain number of procedures. It actually performs more scans than expected, but the costs increase, too. Under a flexed budget, as long as the expenses and revenues balance out, you're fine. A flexed budget represents various levels of production.

Benchmarking: Comparing one radiology department to another based on a predesignated set of criteria. At times, such comparisons may help radiology administrators better govern their spending habits based on similar facilities in similar demographics. But true apple-to-apple comparisons are rare. Before embarking on a benchmarking document, carefully categorize the differences and similarities between organizations.

Annualized: Forecasting year-to-date expenses. Some hospitals formulate a budget at different times of the year. An annualized budget takes the amount of money already spent and extrapolates that spending forward throughout the re mainder of the fiscal or calendar year.

An annualized budget, however, assumes that everything spent in the first six months will be spent again in the next six months. Although that may be partly true with some items, such as staff salaries and basic supplies, other items, such as equipment maintenance costs, may throw an annualized budget out of whack.

Zero-based: This budget begins every year with a clean slate. Under such arrangements, administrators assume a zero-dollar assignment for everything and move forward to justify each line item independent of the work completed the year before.

Under such a budget, managers use historical data but are not governed by it.

Stark, anti-kickback primer

Stark Law

The federal physician self-referral law, commonly referred to as the Stark Law, establishes two basic principles:

1. The referral prohibition: A physician may not refer a Medicare beneficiary to a healthcare entity where a fiduciary relationship exists

2. The billing prohibition: A healthcare entity may not bill for improperly referred services unless an exception applies

Anti-kickback statute

The federal healthcare program's anti-kickback statute is considered the older cousin of the Stark Law.

This broad criminal statute prohibits one person from knowingly and willfully giving, or offering to give, remuneration of any kind as an inducement for business or business referrals for which payment may be made under a federal healthcare program.

Remuneration includes anything of value. The term "inducement" means any act intending to influence a person's judgment (i.e., influence them to refer patients to your facility).

Editor's note: This passage is excerpted from The Compliance Officer's Handbook, published by HCPro, Inc.. To order or for more compliance information, visit www.hcmarketplace.com.

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