Administra9on: Billing, Coding & Documenta9on. Jessica Ellis, M.D. ORA Orthopedics
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1 Administra9on: Billing, Coding & Documenta9on Jessica Ellis, M.D. ORA Orthopedics
2 Standards for Documenta9on AIUM has published standards for each joint The report is a representa8on to the outside world (insurance companies, referring physicians, pa8ents) that MSK U/S is useful and valid. Assume that a radiologist, or someone who believes that radiologists are the gold standard, will eventually examine your records.
3 Documenta9on of Ultrasound Imagining Exams & Guided Procedures On the image itself Pa8ent name & ID# Laterality Body part Orienta8on (transverse, longitudinal) Measurements of all pathologic lesions Video clips (descrip8on of what is visualized)
4 Documenta9on of Ultrasound Imagining Exams & Guided Procedures Create a separate report or create a separate paragraph for your interpreta8on within the clinic visit note. Performing provider Reques8ng provider Diagnosis (ICD- 9 or the future ICD- 10) For ultrasound needle guidance you can include ra8onale for why guidance is necessary. Record the number of different views obtained.
5 Example Report: MUSCULOSKELETAL ULTRASOUND REPORT Name: DOB: MR#: Date: Performing Provider: Reques9ng Provider: Reason for Study (ICD codes) STUDY: (R/L)(Body Part)(Number of dis9nct images) Needle Guidance Procedures need descrip9on and reason for need of guidance. FINDINGS: IMPRESSION:
6 Images as Part of the Medical Record Back up the images from the ultrasound hard drive to an external hard drive Frequency of image back up Store images in the EMR in the pa8ent s file
7 Ge]ng Paid No reported claim denials based on the specialty of the performing provider (non- radiologist) Narra8ve of U/S needle guidance should be clear in the procedure note. Necessity of U/S needle guidance is the most likely issue to arise. Me8culous and complete documenta8on Coding must be precise Try to stay below the radar Do not code for use of Doppler
8 Changes Ahead Bundled codes in 2014 for injec8on and ultrasound ICD- 9 changes to ICD- 10 in October of 2014 Cer8fica8on
9 Which codes do I use? Ultrasound exam Needle guidance Injec8on Supply charge E&M code
10 76881 Ultrasound, extremity, non- vascular, B- scan and/or real 8me with documenta8on, complete CPT Guidelines: A complete ultrasound examina8on of an extremity consists of real- 8me scans of a specific joint that includes examina8on of the muscles, tendons, joint, other sog 8ssue structures, and any iden8fiable abnormality. Private insurance reimbursement Four biggest private insurers in my prac8ce: $271, $203, $206, and $199 Another prac8ce s range $ Medicare reimbursement averages $115 RVU =.59
11 76882 Ultrasound, extremity, non- vascular, B- scan and/or real 8me with documenta8on, limited, anatomic specific CPT Guidelines: A limited, anatomic- specific ultrasound examina8on is performed primarily for evalua8on of muscles, tendons, joints, and/or sog 8ssues. It is a limited examina8on where a specific anatomic structure such as a tendon or muscle Private insurance reimbursement Four biggest insurers in my prac8ce: $71, $56, $53, $52 Medicare reimbursement averages $30 RVU =.41
12 76942 (maybe obsolete in 2015) Ultrasonic Guidance for Needle Placement (eg. Biopsy, aspira9on, injec9on, localiza9on device) imaging supervision and interpreta9on Indica8on for ultrasound guidance Must save an accessible permanent US picture or video of target site. Codes are to be used in conjunc8on with the related ICD9 Procedure codes. Reimbursement: Four biggest insurers in my prac8ce: $352, $342, $291, $225 Average Medicare reimbursement $169 RVU =.67
13 76942 Indica8on for ultrasound guidance Must save an accessible permanent US picture or video of target site. Codes are to be used in conjunc8on with the related ICD- 9/ICD- 10 Procedure codes. Private insurance reimbursement: Four biggest insurers in my prac8ce: $352, $342, $291, $225 Another provider s range for reimbursement $ Medicare reimbursement average is $169 RVU =.67
14 Addi9onal Codes Injec8on & Aspira8on codes may be billed at the same visit: ARTHROCENTESIS, ASPIRATION &/OR INJECTION; MAJOR JOINT/BURSA MEDIUM JOINT/BURSA SMALL JOINT/BURSA INJECTION(S); SINGLE TENDON ORIGIN/INSERTION ASPIRATION &/OR INJECTION, GANGLION CYST(S) ANY LOCATION Other related procedure codes: Venipucture Platelet Rich Plasma Injec8on UNLISTED transfusion medicine procedure Supply codes: Ex: J1040 Depo Medrol 80mg
15 Addi9onal Codes Claims for Bi- Lateral Extremity Ultrasound must have documenta8on to support its medical necessity. Use 50 modifier. E&M codes may be used at the same visit, use 25 modifier with the E&M code Facility fees may also be separately billed
16 Bundled / Unbundled Coding Currently Medicare does not, bundle the extremity ultrasound with the ultrasound guidance, but some private payers may. Separate recorded images and wriqen reports for each study should be maintained in the pa8ent s record. In 2015 these services will be bundled by Medicare. RVUs are yet to be determined.
17 Bundle Ultrasound Guidance w/ Arthrocentesis, Aspira9on and/or Injec9on of a Joint 206X1 Arthrocentesis, aspira8on and/or injec8on, small joint or bursa; with ultrasound guidance, with permanent recording and repor8ng. 206X2 Arthrocentesis, aspira8on and/or injec8on, intermediate joint or bursa; with ultrasound guidance, with permanent recording and repor8ng. 206X3 Arthrocentesis, aspira8on and/or injec8on, major joint or bursa; with ultrasound guidance, with permanent recording and repor8ng.
18 What s your prac8ce se]ng? How is your 8me best used? How are your pa8ents best served by this image modality? How will you get paid for doing MSK ultrasound?
19 Business Plan Proposal for an Ultrasound Machine Understand the start- up costs Research what your prac8ce s reimbursement is for the common ultrasound codes Es8mate the number of procedures/exams that you will likely perform. Calculate the number of procedures to break even. Tax write- off for equipment deprecia8on.
20 Equipment Costs: Ultrasound Machine Buy / lease Warranty Transducers (MHz) Linear, curved Ultrasound Transmission Gel Sterile Covers / kits Printer paper PRP kits Training / cer8fica8on
21 Process Planning Set- up a protocol to be followed. Communicate this to your team. Ordering supplies Pa8ent procedure Consent Discharge instruc8ons Cleaning the equipment Data entry, image documenta8on Backing up images / EMR Coding/billing Monitor denials
22 Ques8ons?
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