Health Information Management

Q&A: Why do we need to report the amount of contrast used?

APCs Insider, August 1, 2014

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Q: We just underwent an audit and the auditor took charges off the claim saying that the radiology report didn’t support the amount of contrast given. We have standard-size bottles that we use and we charge for the bottle. Our system converts the bottle to the number of units because it has a HCPCS code. The department just enters the number of bottles they use. We are not reimbursed for the contract, so what is the auditor’s issue?
A: Reimbursement is not the deciding factor here, but several factors do come into play. From a clinical standpoint, the amount of contrast given to a patient is significant information–for the provider, the patient, and the physician.
Contrast can affect a person’s renal function, so it's a best practice to document the amount of contrast provided to a patient. If a patient has problems with renal function, the amount of contrast and other drugs/biologicals that can affect the kidneys becomes very important.
From a billing and coding standpoint, the documentation in the medical record must support the number of units reported. CERT reviews have noted the lack of documentation to support the number of units billed for items and services that are packaged under the OPPS.
Whether separate payment is made for the line item or the line item is packaged, the documentation must support the item or service. Providers want to ensure that the documentation in the record supports the item/service that was provided, so the cost is included in information provided to CMS. While the individual line item my not be reimbursed separately, the cost is captured to represent the actual resources involved in caring for the patient.
See here for more information on packaged services from CMS.
Editor’s note: Denise Williams, RN, CPC-H, seniorvice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Florida, answered this question.

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