Radiology Administrator's Compliance & Reimbursement Insider, August 2007

“We feel we have to overcomplicate our writing,” said Larson, who spoke at the Radiology Business Management Association annual conference in St. Louis in May. “It’s a curse of the 21st century. We seem to think if we don’t use big words then our memo, or letter, or policy change won’t seem important enough.”

Learn the simple rules

In healthcare, as elsewhere, nearly every manager tends to convolute the written word, Larson said. 

Certainly, no one expects you to compose Shakespearian sonnets about the next radiology coding compliance policy change. (Why write “One must expect that the general population of the genus Rosa tends to cultivate at least one barb” when you could write “Every rose has its thorn”?) But your staff members expect you to communicate changes effectively. 

Larson said written communications should: 

Get organized

Organize your thoughts prior to putting your pen to paper. It will improve your writing significantly. No amount of polishing can mend a poorly crafted document. Follow Larson’s steps to organize what’s on your mind and communicate it on paper: 

1. Form your big idea. Always have a theme. If you don’t know exactly what you want to say, it will be impossible for you to write a strong document.

2. Know your audience. Figure out who you want to read your document. Executives, technologists, radiologists, vendors, and the general public all approach data from different perspectives. Create your document with your specific audience in mind. Explain the items that the particular audience needs to know about most. 

3. Make your point. Explain the three or four most important points that you need to make. “Remember the rule of threes,” Larson said. “Readers and listeners generally aren’t able to absorb groups of more than three. So try to limit your message to two or three essential points whenever possible.” Also, tell your audience what you want them to do. Big business experts call this the ‘call to action’ or ‘action items.’ 

Create a thought bucket

Visualize your point by sketching out your memo. Put your “big idea” in the center of the page, and surround it with the things that you need to say. Create buckets of common thoughts or messages. Put everything that’s similar into its proper bucket. Position these buckets around the big idea, and include supporting data and other information.

Now, think about the beginning, middle, and end of your document. Introduce your main idea, and then support it with examples, documentation, and information. Explain why your main idea is important. Conclude your document with what you want your audience to do with the information you just provided. 

Be concise

Frequently, managers use too many words to describe a simple concept, Larson said. Take the following example of a recent radiology department memo:

Going forward all current and future employees should operate within the hospital’s new basic radiology coding system regardless of departmental roles and relative job descriptions as this new computerized programming will allow the administration to track, audit, and report appropriate use and reimbursement of radiology procedures.

Now consider the following, more readable version of the same memo: 

As of July 1, please use the new coding software. This new program provides better patient service and ensures that we get paid appropriately for the work we do.

The latter version efficiently informs the reader of the important points, such as who (everyone), what (implementation of a new computer program), when (July 1), and why (to receive proper reimbursement).  

Insider source

Paul Larson, president, Paul Larson Communications, 1017 Greenleaf Street, Evanston, IL 60202, 647/475-1283;larsonpw@hotmail.com.

Ask the Insider

CMS transmittal clarifies some teleradiology confusion

Q: Here’s the scenario: A hospital contracts with a radiology group to interpret radiology images. The hospital bills the technical portion, and the radiology group bills the professional services. The radiology group subcontracts with a service that employs a radiologist overseas to do a preliminary read for radiology exams that the hospital performs after hours. The radiology group then overreads the film and bills the professional fee. 

Does this arrangement between the radiologist and overseas provider make both the professional fee handled by the radiology group and technical fee billed by the hospital not payable by Medicare? Or do the Medicare rules regarding reimbursement for overseas payments apply only to the services that the radiologist provides, because that portion involves overseas services?

A: CMS Change Request 5427, Medicare Benefit Policy Manual, Transmittal 66, amends Chapter 16, Section 60, of the manual to add the following paragraph:

Payment may not be made for a medical service (or a portion of it) that was subcontracted to another provider or supplier located outside the United States. For example, if a radiologist who practices in India analyzes imaging tests that were performed on a beneficiary in the United States, Medicare would not pay the radiologist or the U.S. facility that performed the imaging test for any of the services that were performed by the radiologist in India.

The payment limitation applies only to the portion of the service furnished outside of the United States, says Hugh E. Aaron, MHA, JD, CPC, CPC-H, senior vice president of compliance and regulatory affairs/regulatory counsel for HCPro, Inc., in Marblehead, MA.  

But if the radiology technologist performs the technical component of the radiology service within the United States, the payment limitation described in the transmittal does not apply, says Aaron, who clarified the information with CMS representative Fred Grabau. 

So an American facility may bill for the technical component even if a radiologist interpreted the image in another country as long as the hospital billed Medicare separately for the technical component.   

Medicare always had very limited coverage for services outside of the United States, says Regulatory Specialist Peggy S. Blue, MPH, CPC, of HCPro, Inc.

“In fact, if it was not for the advent of telemedicine, this transmittal would probably not have even been necessary,” Blue says. “I know it can be very attractive for patients to seek medical services in other countries due to a significant cost savings in their out-of-pocket expenses, but I don’t see practitioners going that way.”

However, for a variety of reasons, both radiology practices and hospital administrations increasingly look to overseas radiologists to perform the professional component of exams. 

Under these arrangements, the overseas physician provides a preliminary read, and the United States–based radiologist provides an overread. 

The United States–based physician then bills Medicare for the interpretation of the exam. 

CMS has received several inquiries regarding whether radiologists providing professional interpretations in the United States can bill Medicare after receiving preliminary reads performed abroad. 

However, CMS “has not yet decided whether it will issue any guidance or clarification,” Aaron says.

Insider sources 

Hugh E. Aaron, MHA, JD, CPC, CPC-H, senior vice president of compliance and regulatory affairs/regulatory counsel, HCPro, Inc., 200 Hoods Lane, Marblehead MA, 978/639-1872; haaron@hcpro.com.

Peggy S. Blue, MPH, CPC, regulatory specialist, HCPro, Inc., 200 Hoods Lane, Marblehead MA, 717/284-3479; pblue@hcpro.com.

CMS set to roll out new ABN form

CMS announced several changes to the advanced beneficiary notice (ABN) in the February 23 Federal Register. 

Healthcare providers use ABNs to inform patients of their potential financial liability for services that Medicare won’t cover. 

CMS published a final draft of the proposed changes on May 25 with the anticipation that these changes would take effect following the final 60-day comment period and the subsequent approval of the final rule. 

Changes include the:

According to the draft, CMS’ goal is to “design a form that is clear and understandable for beneficiaries, while permitting appropriate customization by the various types of providers, practitioners, and suppliers that use ABNs.”

Essentially, CMS wants to combine the two traditional forms into one usable and easy-to-follow document, said Bill Malm, president of Health Revenue Integrity Services in Cleveland, who spoke during the HCPro, Inc., audioconference “Radiology ABNs: Ensure compliance and appropriate reimbursement” on June 13. 

“This form could be used by different specialties, and it would be more user-friendly, with language the patient can understand,” Malm said.

Editor’s note: To view a draft of the new ABN, see the sample ABN on p. 4 of the PDF of this issue. To learn more, visit the CMS Web site and click on the Paperwork Reduction Act of 1995. Then click on PRA Listing and search for CMS-R-131. 

Insider source 

William L. Malm, ND, RN, president, Health Revenue Integrity Services, Inc., 815 Brick Mill Run, Westlake, OH 44145, 440/331-3312; wmalm.hris@adelphia.net.

Tackle these topics prior to providing radiology ABNs

Q: A patient came to our facility for preoperative chest x-rays three days before surgery for cardiac bypass. Should we have administered an advanced beneficiary notice (ABN)?

A: First determine which payer provides coverage for the patient—Medicare, Medicaid, private, or commercial. Most insurers consider preoperative x-rays to be screening exams unless the scan helped surgeons gather information necessary for the operation, said Larry Balmer, chief compliance officer at Radiology Incorporated in Mishawaka, IN. Balmer spoke during the HCPro, Inc., audioconference “Radiology ABNs: Ensure compliance and appropriate reimbursement” on June 13. 

Most carriers, Balmer said, initially deny the pre-operative chest x-ray claim. However, once they receive a claim with supporting documentation, carriers usually will reimburse for the exam. 

If dealing with a Medicare patient, check the local coverage determination for the procedure and determine whether the exam meets medical necessity, said Bill Malm, president of Health Revenue Integrity Services in Cleveland, who also spoke during the audioconference. 

Only the Medicare program uses an ABN form. So, if Medicaid is the patient’s primary insurer, don’t use an ABN, said Malm. Consult the state Medicaid carrier to determine coverage requirements, he added. 

However, do not give an ABN to a non-Medicare patient unless specifically required under a contractual arrangement with the non-Medicare payer, Malm said.

Although ABNs are specific to Medicare, some state Medicaid agencies, such as Indiana, require providers to inform Medicaid patients about potential noncoverage of a service. Further, many state groups encourage healthcare providers to make note in the medical record that the facility told the patient about his or her fiscal liability. 

Many payers require preauthorization, which precludes the necessity of an ABN. In that case, referring physicians must obtain permission or “preapproval” prior to the performance of a preoperative x-ray. 

Some states allow you to charge a patient for the service if he or she was presented with a choice.

If you suspect that Medicaid won’t cover the preoperative x-ray, document that you informed the patient. That way, if Medicaid denies the bill, you can bill the patient directly, Balmer said. 

When dealing with situations involving questionable services and Medicaid, obtain an ABN as a blanket protection, said Malm.

Insider sources 

Larry W. Balmer, CCP, compliance officer, Radiology Incorporated, 620 Edison Road, Suite 110, Mishawaka, IN 46545, 901/516-0818; lbalmer@rad-inc.com.

William L. Malm, ND, RN, president, Health Revenue Integrity Services, Inc., 815 Brick Mill Run, Westlake, OH 44145, 440/331-3312; wmalm.hris@adelphia.net.

Assess compliance awareness with regular staff reviews

As you develop and implement your compliance plan, look for every opportunity to generate employee feedback and reinforce your commitment to compliance. Take the pulse of your organization through conversations with staff members. Periodic performance reviews (PPR)—those regularly scheduled staff appraisals—provide excellent opportunities to find out what’s going on.

The Office of Inspector General says radiology managers should discipline employees who violate compliance policies and procedures. You need to find out whether your employees follow your policies and procedures and whether those policies and procedures are working first. 

For example, do employees have trouble understanding your policies and procedures? Do they mistakenly believe that those policies and procedures are unimportant?

Regular performance reviews are the most direct route to obtain answers about your compliance program. You can get some of your most valuable compliance feedback when you sit down face-to-face with your radiology technologists and other staff members and discuss their concerns. If you go into each review with a predetermined set of compliance questions, you’re more likely to get consistent feedback.

Draft a list of questions and distribute it in a memo to all staff members who conduct performance reviews. A memo will instruct reviewers about how to incorporate the compliance questions into their regular set of review inquiries. 

Sample questions

1. Do you keep a copy of our code of conduct and our compliance policies handy? Encourage employees to have compliance materials readily available at their work stations or another easily accessible -location. Consider creative ways to keep these valuable tools within easy reach.

2. Have you ever consulted our code of conduct or compliance policies? Find out whether your staff members actually use your compliance resources in their day-to-day work. The best compliance plan in the world isn’t worth anything if your employees don’t use it. 

If they say they do use these compliance resources, find out how. Probe further to determine whether they use the resources correctly, whether the resources are helpful, or whether employees run into any difficulties when using the resources.

3. Are the compliance policies easy to understand? Do they help you do your job? Staff members sometimes believe compliance concerns are simply too difficult to understand and inappropriately complicate the healthcare routine. 

When an employee refers to this difficulty, press him or her for examples of specific procedures and request a detailed account of how staff members attempt to work within the procedure and how he or she deals with the problem. Such input will help you rewrite your policy and review complex procedures, making compliance easier throughout the radiology department or facility.

Editor’s note: The above excerpt is from the Radiology Manager’s Handbook: Tools and Best Practices for Business Success. For information, visit www.hcmarketplace.com.

Coding corner

Determine the difference between CT and CTA

by Melody W. Mulaik, MSHS, CPC, CPC-H, RCC

CTA has become a hot topic for radiology during the past few years. CTA reimbursement, equipment requirements, and joint venture relationships between cardiologists and radiologists for the interpretation of CTA have generated much discussion in the radiology community.  

Coders find it difficult to assign a CTA procedure code that accurately represents the service that the radiologist performed according to the standard definition of CTA procedures. 

By definition, all CTA procedure codes, except the category III cardiac codes, include the following verbiage: “without contrast material(s), followed by contrast material(s) and further sections, including image postprocessing.”

Coding by definition 

According to the AHA Coding Clinic for HCPCS (volume five, number one, first quarter 2005), “the portion of the CTA exam referred to as ‘without contrast material(s)’ represents the images taken to calibrate the scanner and to identify the anatomic region to be evaluated during the ‘with contrast’ portion of the study.”  New CT scanners have more advanced technology that has nearly eliminated the need for calibration images.  

Clinical Examples in Radiology (volume one, issue three, summer 2005) also states, “When a localizer image is not obtained, it is still appropriate to report the CTA procedure codes. In such circumstances, a reduced service modifier is not required.” This clarification is important, because many organizations have expressed concern that the “without contrast” portion actually refers to diagnostic images, contrary to the Coding Clinic definition. The bottom line—if the exam occurs without initial noncontrast images, this does not change the code assignment.

Determining postprocessing

Radiology coders and administrators face another challenge, as well. Despite the fact that the radiologist, or radiology technologist, documents the procedure in the report, the administrator or coder must ensure that the required “postprocessing” was performed and -properly documented in that report. 

Imaging postprocessing refers to two-dimensional (2-D) and/or three-dimensional (3-D) reconstruction(s) of the CT data set acquired during the imaging process. The 2-D reformatted images can be created in multiple planes (e.g., sagittal), then interpreted, annotated, and archived as hard-copy and/or electronic files. The radiologist typically evaluates 3-D or volume-rendered reconstructions in multiple projections. The 3-D reformatting requires extensive effort from the radiologist, who typically performs the processing on a separate workstation. The CPT Manual lists separate procedure codes for 3-D rendering (76376 and 76377); however, do not assign these in addition to the CTA codes, because the CTA procedure codes already include the work that these codes define.

CT imaging of an anatomic region is not always considered CT angiography, even if the primary concern involves the blood vessels. The key distinction between CT and CTA is that CTA includes image postprocessing, such as maximum-intensity profile or 3-D renderings. A CTA study includes: 

Understanding common confusions

The most frequent coding mistake arises from CT scans to evaluate for pulmonary embolism. Coding these as CTs or CTAs depends on the actual procedures that the radiologist performed and documented. 

If the radiologist performed the CT specifically for the purpose of viewing the pulmonary vessels and he or she performed image postprocessing (sagittal, coronal, 2-D, 3-D, or multiplanar reconstructions), then it meets the definition of a chest CTA (71275). 

However, many CT scans that evaluate for pulmonary embolism are not CTAs. They are simply CTs. The radiologist must perform and document the image postprocessing in order to bill for a CTA.  

Discuss the “CT Pulmonary Embolism” protocol with radiologists and technologists to ascertain what process they follow. Do not assign the procedure code based on protocols, but by understanding the nuances of the actual procedure. Such awareness allows you to provide feedback to the radiologist, if documentation is inadequate, to ensure correct coding for the performed procedure.

Editor’s note: Mulaik is copresident of Coding Strategies, Inc., in Powder Springs, GA. Contact her at Melody.Mulaik@CodingStrategies.com.

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