How to Get Paid for. Today s s Agenda:

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1 How to Get Paid for Imaging Services Performed in Surgery John Marshall CRA, RCC, RT(R), FAHRA Disclaimer John Marshall, his wife Adrienne and their dog Shakespeare, specifically disclaim liability or responsibility for the results or consequences of any actions taken in reliance on anything in this presentation or the accompanying materials. We also apologize for any and all embarrassing remarks that come out of John s mouth during this presentation. The information provided in this presentation is subject to change without notice as a result of changes in reimbursement laws, regulations, rules, policies, and payment amounts. All content in this presentation is informational only, general in nature and does not cover all situations or all payers rules and policies. This content is not intended to instruct hospitals and/or physicians on how to use or bill for healthcare procedures including new technologies outside of Medicare national guidelines. A determination of medical necessity is a prerequisite that is assumed to have been made prior to assigning codes or requesting payments. Hospitals and physicians should consult with appropriate payers, including Medicare fiscal intermediaries and carriers, for specific information on proper coding, billing and payment levels for healthcare procedures. This presentation represents no promise or guarantee concerning levels of reimbursement, payment, coding, billing and coverage issues. Today s s Agenda: Getting Paid Regulations and Obstacles Turf Battles and Politics Fluoroscopy and RS&I Real-Life Examples Solutions and Options

2 GIVE US BACK OUR SURGERY CHARGES!

3 How to Get Paid for Imaging Services Performed in Surgery John Marshall CRA, RCC, RT(R), FAHRA Executives and the BOD Bottom Line Radiologic Technologist FTE/UOS

4 AR Days Patient Account Biller Regulations and Obstacles 2008 HOPPS Packaging Policies Image Processing Radiopharmaceuticals and Contrast Media Supervision & Interpretation Services Guidance Intra-Operative Services

5 Packaged Interoperative Services Services provided in support of other dependent minor procedures or diagnostic testing. Intravascular US Follow-Up Angiography Operative Hip Thyroid Met Uptake Operative Cholangiogram Wall Motion Add-On Ejection Fraction Add-On First Pass Add-On Bundling Versus Packaging Bundling Coding Term Applied to Sub-Components Not Reported Separately Packaging Financial Term Reimbursed Elsewhere Reported Separately Packaged Services MUST Be Reported! We encourage hospitals to report all charges for all services on claims for data on which the relative weights are set. This will insure the accurate reporting of the relative costs for all services. Fed Reg, Volume 68 #216 Nov. 7, 2003, Pg 63425

6 Yes, the Hospital still gets reimbursed. Gall Bladder 2007 $4,499 + $107 Cholangiogram 2009 $6,366 Includes all charges Hip Pinning 2007 $10,625 + Fluoroscopy + $76 OR Hip 2009 $11,346 Includes all charges Turf Battles Component Coding Surgical Procedures Require Component Coding Anesthesia Surgeon Operating Room Time = Procedure Code Imaging RS&I Procedures Drugs and Contrast Implantable Supplies

7 Billing Issues Surgical Component RS&I Component NCCI Edits Bundling Packaging Operating Statistic = Minutes and Levels (soft codes) Imaging Statistic = Units of Service (cpt) Professional Fee: Radiologist versus Surgeon Suggested Compromise Performing Physician Reports RS&I Operating Room Reports Surgical Codes Imaging Reports RS&I Codes (70000 series) Statistical Charges for NCCI Substitution Consider Additional Hour Statistics FLUOROSCOPY

8 ACR Guidance on Fluoroscopy Fluoroscopy is considered a part of such procedures as gastrointestinal exams - arthrography myelography - cholecystography venography - angiography arteriography - cystography and is not coded separately. AMA Guidance Radiologic supervision and interpretation codes for specific procedures include all the radiologic services necessary for that procedure. For example, do not additionally report fluoroscopy (e.g., CPT codes 76000, 76001, 77002, 77003) or ultrasound guidance (e.g., CPT codes 76942, 76998)." CPT Assistant, February 2007 National Correct Coding Initiative NCCI Manual, Chapter 9 "Unless specifically noted, fluoroscopy necessary to complete a procedure and obtain the necessary permanent radiographic record is included in the major procedure and should not be reported separately."

9 Fluoroscopy Fluoroscopy (separate procedure), up to one hour physician time Designated as a separate procedure Status T Inherent in all RS&I codes Reported when fluoroscopy is the only imaging performed and no radiographs produced Subject to NCCI Edits With Other Procedures T T T T T T T Fluoroscopy 76001, Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician May Be Billed With Other Procedures Status N Not Paid Separately By Medicare Inherent in all RS&I codes May be reported for >53 minutes of dedicated staff and equipment availability Reported when fluoroscopy is the only imaging performed and no radiographs produced

10 76001, Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician Over 53 Minutes = One Hour (Rule 882) Dedicated Technologist and Equipment NOT Fluoroscopy Time 76001, Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician All CPT codes are not restricted to a specific specialty group. Any CPT code may be used to designate the procedures or services rendered by a qualified physician or other qualified healthcare professional 2010 cpt Professional Edition, Introduction Central Venous Access - Fluoroscopy 77001, Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure) Statistical Charge : Post CVC Placement CXR

11 Localization and Needle Placement Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) Only Non-Spinal Needle Placement Performed Do Not Report With an RS&I Code More Likely to Occur in Pre-OP or Recovery Pain Injections Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve, or sacroiliac joint), including neurolytic agent destruction Predominately Pain Management Do not report with RS&I Do not report with Facet Injections ( ) Pacemakers Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation Reported for both pacemakers and defibrillators Report post-implant Chest radiograph separately

12 Surgery Reports Surgical Components Radiology Reports RS&I or Statistic A/V Dialysis Description of Procedure: Local anesthesia was applied in the graft apex and a small skin incision was made. Graft was accessed medially towards the venous anastomosis. Fistulagram was performed showing Original Charge Reported: < One Hour Fluoroscopy Arterial Anastomosis DIALYSIS IN FLOW GRAFT Brachial Artery OUT FLOW Basilic or Cephalic Vein Venous Anastomosis A/V Dialysis Original Charges Corrected Charges Fluoro <1 Hour $0 N/A Statistical Charge $ AV Fistulagram $ AV Fistulagram $157 $157 $157 APC Reimbursement: Units of Service: $0 +1 Statistic Charge needed for AV Fistulagram as Only Procedure

13 A/V Dialysis Description of Procedure: Local anesthesia was applied in the graft apex and a small skin incision was made. Graft was accessed medially towards the venous anastomosis. Fistulagram was performed showing clot and stenosis of radial artery beyond the anastomosis. was angioplastied with a 7 mm x 4 cm balloon, and there was immediate recoil with a persistent 80% stenosis. This was then stented with a 10 mm x 25 mm Express stent with no residual stenosis. Original Charge Reported: Fluoro One Hour A/V Dialysis Original Charges Corrected Charges Fluoro <1 Hour $ RS&I Angioplasty Venous $ A/V Fistulagram $ A/V Fistulagram $ Angioplasty - Venous $1, Angioplasty - Venous $1, Vascular Stent Plcmnt $6, Vascular Stent Plcmnt $6, RS&I Vasc Stent Plcmnt $0 $6,357 $6,357 APC Reimbursement: Units of Service: $0 +2 Surgery Reports Surgical Components Description of Procedure: Spine Fluoroscopy Following preparation and draping of the skin and under fluoroscopic control, 20 gauge needles were inserted into the disc spaces at the L2-3, L3-4 and L4-5 levels. Contrast was injected and the level of pain was determined. Original Charge Reported: Fluoro One Hour

14 Spine Fluoroscopy Original Charges Fluoro <1 Hour $ RS&I Discogram $1, Inject Discogram $ RS&I Discogram $ Inject Discogram $ RS&I Discogram $ Inject Discogram $ Inject Discogram $ Inject Discogram $ Inject Discogram $0 $0 $2,958 APC Reimbursement: Units of Service: Corrected Charges $2, Discograms are coded per each vertebral disc injected Description of Procedure: Laminectomy Following successful induction of general anesthesia, The left cervical region was prepped and draped in a sterile fashion. Fluoroscopy was used to identify the appropriate level. The spinous processes of C-3 and C-4 were resected. Original Charge Reported: Fluoro Less Than One Hour Laminectomy Original Charges Corrected Charges Fluoro <1 Hour $ Single View Spine $44 $0 $44 APC Reimbursement: $44 Units of Service: Fluoroscopy is included in all spinal surgeries.

15 Pacemaker DESCRIPTION OF PROCEDURE: The patient brought to the operating room The ventricular lead was passed first. The battery pack then as mentioned was a St. Jude model #PM2210, was implanted in the pocket and the pocket was closed in three separate layers. Original Charge Reported: Fluoro <1 Hour and Pacer Fluoroscopy Pacemaker Original Charges Corrected Charges Fluoro <1 Hour $0 n/a Chest Single View $ Single View Spine $ Pacemaker Fluoro $ Pacemaker Fluoro $0 $0 $0 APC Reimbursement: $0 Units of Service: OR -1 Rad +1 Check the Surgery Department s Standard Charges or Preference Card Central Venous Access DESCRIPTION OF PROCEDURE: Venous aspirate was without resistance and the wire was passed without resistance. The fluoroscopy was used to confirm adequate positioning of the wire into the vena cava. The catheter was cut to the appropriate length and secured to the port. The port was aspirated and flushed with no resistance to flow. The final position was confirmed with fluoroscopy. Original Charge Reported: CVC Fluoro and Chest Single View

16 Central Venous Access Original Charges Corrected Charges Fluoro <1 Hour $ Insert Venous Catheter $ Chest Single View $44 none Chest Post CVC Fluoro statistic $44 $0 APC Reimbursement Change: ($44) Units of Service: OR -1 Rad +1 CVC Fluoroscopy includes post radiograph - Statistical Charge Suggested Breast Specimen PROCEDURE IN DETAIL: incision we then were able to identify the wire and the wire was then brought out through the incision. Now with a wire being used as a guide, we were then able to perform an excision encompassing the area of concern. Specimen radiograph showed only partial area of concern and did not include all of the micro-calcifications This specimen mammogram did confirm that we had the entire area of concern Original Charge Reported: Specimen Radiograph Breast Specimen Original Charges Corrected Charges Specimen Radiograph $ Specimen Radiograph $ Specimen Radiograph $183 $366 $549 APC Reimbursement Change: $183 Units of Service: + 1 Specimen Charge is per Radiograph Also Reported for Non-Breast Specimens

17 Cholangiogram PROCEDURE IN DETAIL: The cystic duct was dissected free. A clip was placed on the gallbladder side of the duct. The duct was opened. A cholangiocatheter was inserted. Half and full strength cholangiogram was performed. There was an obvious filling defect Cholangiocatheter was injected There were no obvious defects. Original Charges Reported: Fluoro <1 Hour and OR Cholangiogram Cholangiogram Original Charges Corrected Charges Fluoro Over One Hour $ OR Cholangiogram $ OR Cholangiogram $ Add'l Cholangiogram $0 $0 $0 APC Reimbursement Change: $0 Units of Service: + 1 Intraoperative Cholangiogram are Reported Per Set (Injection) ERCP PROCEDURE IN DETAIL: The endoscope was inserted cannulated the cystic duct We then turned our attention to the pancreatic duct cannulated the pancreatic duct Original Charges Reported: Fluoro <1 Hour and OR Cholangiogram

18 ERCP Original Charges Corrected Charges Fluoro Over One Hour $ ERCP Bile & Pancreatic $0 $0 $0 APC Reimbursement Change: $0 Units of Service: + 1 ERCP has three RS&I Codes Available, Determined by Cannulation(s) Biliary Duct Guide Catheter Cannula Pancreatic Duct Both Bile & Pancreatic John s s Guidance When someone asks what you did in surgery your answer is what you should charge. AVOID REPORTING C-ARM C FLUOROSCOPY. Report the specific, appropriate CPT code.

19 Suggestions and Guidance Educate Your Staff Resolve Turf Issues Surgical Components to OR RS&I Components to Radiology Professional Fees???? Determine Productivity Statistics OR Minute Style Billable UOS Hybrid Combination Establish Statistical Charges Suggested Statistical Charges CDM # Department Description REV CPT Price 387XXXX RADIOLOGY POST CVC FLUORO CHEST 999 (none) $ XXXX RADIOLOGY PORTABLE CHEST $ Chest Post Central Venous Catheter Fluoroscopy A/V Fistulagram In Surgery Facet Injection in OR OR Fluoroscopy NCCI (No RS&I to report) Fluoroscopy in Surgery 1 Hour (No RS&I to report) Fluoroscopy In Surgery 2 Hours (No RS&I to report) Fluoroscopy In Surgery 3 Hours (No RS&I to report) C-ARM CHARGE CROSSWALK Note: Charge for radiographs or c-arm images according to the number of views ARTERIOGRAQPHY Use ALL Appropriate RS&I VARIES Report RS&I Codes By Vessel(s) Imaged BILE DUCT Biliary Duct Guide Catheter Pancreatic Duct Guide Bile & Pancreatic Guide Bile Duct Dilation Only Report One per OR Session BREAST OR TISSUE SPECIMEN Specimen Radiograph (each) Report for Each Radiograph BRONCHOSCOPY Imaging Is Included STATISTIC Included In Bronoscopy - Use Statistical 'Charge' Percutaneous BX Once Per Lesion

20 C-ARM CHARGE CROSSWALK Note: Charge for radiographs or c-arm images according to the number of views ARTERIOGRAQPHY Use ALL Appropriate RS&I VARIES Report RS&I Codes By Vessel(s) Imaged BILE DUCT Biliary Duct Guide Catheter Pancreatic Duct Guide Bile & Pancreatic Guide Bile Duct Dilation Only Report One per OR Session BREAST OR TISSUE SPECIMEN Specimen Radiograph (each) Report for Each Radiograph BRONCHOSCOPY Imaging Is Included STATISTIC Included In Bronoscopy - Use Statistical 'Charge' Once Per Lesion Percutaneous BX ERCP Biliary Duct Guide Catheter Cannula Pancreatic Duct Both Bile & Pancreatic Only Report One of These Per OR Session FLUOROSCOPY Less Than 60 Minurtes STATISTIC Included In All OR Procedures- Use Statistical 'Charge' More than 60 Minutes Do Not Report With Radiographs Pacemaker Includes Fluoroscopy and Radiographs In OR Suite Central Venous Access Includes Fluoroscopy and Post Radiograph GI TRACT Guide Intubation Includes Fluoroscopy and Radiographs In OR Suite Dilation Esophagus Includes Fluoroscopy and Radiographs In OR Suite HIP Intraoperative Includes Fluoroscopy and Radiographs In OR Suite In Recovery (1 or 2 Views) Pelvis or AP & Lat INTERVENTIONAL VASCULAR IMAGING - Use CPTs VARIES All Imaging Codes By Anatomy Visualized Angioplasty - Extremity Once Per Vessel Angioplasty - Add'l Extremity Once Per Each Additional Vessel Angioplasty - A/V Dialysis Once Per Vessel Angioplasty - Renal First Once Per Vessel Angioplasty-Renal Each Add'l Once Per Vessel Angioplasty -Venous Once Per Vessel Stent Placement - First Once Per Vessel Stent Placement Each Add'l Once Per Vessel Embolization Once Per Surgical Field Thrombolysis Once Per Surgical Field Thrombo Catheter Exchange Once Per OR Session Venography - Extremity (unilat) Once Per Extremity Venacavagram Inferior Not Reported With Cava Filter Plcmnt Venacavagram Superior Not Reported With Cava Filter Plcmnt

21 INTRODUCTION/GUIDANCE GI Tube (Miller Abbot Type) Includes Fluoroscopy and Radiographs In OR Suite Needle Biopsy Includes Fluoroscopy and Radiographs In OR Suite Percutaneous Drainage Tube Includes Fluoroscopy and Radiographs In OR Suite Spine Injections (Ndl Plcmnt) Includes Fluoroscopy and Radiographs In OR Suite IVC FILTER PLACEMENT Cava Filter Placement Do Not Report Cavagram SPINE Guide Catheter/Needle Disc or Vertebral Biopsey and Spinal Injections Discogram Cer/Thor (each) Report Per Disc Injected Discogram Lumbar (each) Report Per Disc Injected Kyphoplasty Thoracic (each) Report Per Vertebral Body Kyphoplasty Lumbar (each) Report Per Vertebral Body Vertebroplasty (each) Report Per Vertebral Body Biopsy Vertebra Report Per Vertebral Body Localization (or Single View) Spine Level Determination (permanent image) URINARY Cystourethroscopy, Diagnostic Fluoro Only - No Films Lithoptripsey STATISTIC Included In OR Procedures- Use Statistical 'Charge' Lithoptripsey - US Ablation Renal US Ablation has an RS&I code Dilatation, Ureter or Urethera Diagnostic RPG requires modifier (-59) Retrograde Urography Unilateral - Report Second Side With RT/LT (-50 or -59) VENOGRAPHY Use ALL Appropriate RS&I VARIES Report RS&I Codes By Vessel(s) Imaged SINGLE VIEWS Spine, Single View Per Imaging Order Joint, Single View Per Imaging Order SPONGE COUNT Abdomen Once Per Exam Pelvis Once Per Exam Chest Once Per Exam STRESS JOINT Fluoro Joint Under Stress Includes Unaffected Side

22 Arteriovenous Dialysis Interventions Thank you for allowing me to spend some time with you today. I hope you were entertained, learned something or at least had a nice nap. John Marshall CRA, FAHRA, RCC, RT(R) john-marshall@smh.com (941)