Coding and Compliance:

Transcription

1 Coding and Compliance: Bettering The Bottom Line Richard Duszak, MD, FACR, FSIR, RCC CPT Advisor, American College of Radiology Chair, ACR Committee on Coding and Nomenclature Editor-in-Chief, Clinical Examples in Radiology

2 CME Objectives Understand nomenclature and concepts fundamental to radiology coding and reimbursement. Develop a framework for improving a practice s coding and billing operations. Institute simple steps into daily practice routines that will facilitate reimbursement and optimize regulatory compliance.

3 This is a Real Case $1,600,000 Settlement Agreement. No Admission of Guilt.

4 And So is This $2,500,000 Settlement Agreement. No Admission of Guilt.

5 Who Will Be Next?

6 Agenda Concepts of compliance Basic coding definitions Fundamental coding rules Rules of medical necessity Actual compliance models Case studies: documentation

7 Fraud and Abuse Prosecution Fraud and abuse identification and prosecution a priority for: CMS and OIG of HHS Individual Medicare carriers Definitions important

8 Fraud and Abuse Definitions Fraud intentional or deliberate misrepresentation to result in an unauthorized benefit, or reckless disregard of the law to result in an unauthorized benefit Abuse incidents or practices that are inconsistent with accepted medical or business practices

9 Coding Errors are Common Evaluation and management coding 205 responding family physicians Across Illinois 6 hypothetical patient encounters Errors in 48% King MS. J Am Board Fam Pract 2001; 14:

10 Coding Errors are Common Interventional radiology coding 62 practicing IR physicians 23 hospitals 549 real patient encounters Initial physician coding assessed Errors in 56% Duszak R. JACR. 2004; 1:

11 Fraud and Abuse: A Way Out! Even ethical physicians (and their staffs) make billing mistakes and errors. When physicians discover that their billing errors, honest mistakes, or negligence result in erroneous claims, the physician practice should [be able to] return the funds erroneously claimed, but without penalties If they have an appropriate plan in place! OIG. Federal Register 2000; 194:

12 Compliance Plan We care about correct reimbursement Regimented billing QI program Stated plan Compliance officer Due diligence Ongoing audits, education, training and improvements

13 Compliance = CQI Provider reimbursement comes only after Service provided, then Coded appropriately, then Billed correctly, then Carrier makes payment Mistakes are expected But...they need to be minimized And corrected when identified

14 Get Certified! OIG model compliance plan for physician practices encourages coder certification Larger practices have higher burdens

15 Definition: CPT aka CPT-4 or CPT-2004 Current Procedural Terminology WHAT service was rendered

16 Basics: Category I CPT Codes procedures radiology laboratory medicine medicine

17 CPT Choices Must Be Accurate! CPT Instructions: Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code.

18 Basics: CPT Service code examples = frontal and lateral chest = adult PICC line placement

19 Definition: ICD aka ICD-9-CM International Classification of Diseases WHY a service was rendered

20 Basics: ICD Diagnosis code examples extremity atherosclerosis w/ ulceration = pneumonia, aspiration, due to food = rule out (whatever) =???

21 Basics: ICD-9 Coding Physicians ordering diagnostic tests are required to provide sufficient diagnostic information so that testing entities can submit accurate claims. But, there is no jeopardy for not doing so! BBA 1997 PM AB , effective January 1, 2002

22 Basics: ICD-9 Coding Convention for diagnosis coding: Official ICD-9-CM guidelines supported by CMS ICD-9 rules apply to hospital, outpatient, and office settings. Rule: code to highest level of specificity BBA 1997 PM AB , effective January 1, 2002

23 CXR Diagnosis Coding 1 Order: cough and fever Exam: pneumonia ICD-9: pneumonia

24 CXR Diagnosis Coding 2 Order: cough and fever Exam: negative ICD-9: cough, fever

25 CXR Diagnosis Coding 3 Order: rule out pneumonia Exam: pneumonia ICD-9: pneumonia

26 CXR Diagnosis Coding 4 Order: rule out pneumonia Exam: negative ICD-9:???

27 Medical Necessity Various definitions Clinical information must support the need for the service provided.

28 Medical Necessity: Example CT abdomen with contrast (72193) YES: appendicitis , 541, 542 NO: headache ICD-CPT concordance = medical necessity

29 Advance Beneficiary Notice (ABN) Medicare requires that patients sign an ABN when services may be denied as unreasonable and unnecessary for the diagnosis, condition or treatment submitted. ABN must be written, signed, and dated. 1 year limitation on ABN A routine ABN not acceptable

30 Signature here means you can bill the patient

31 Correct CPT Coding: Systems Contemporaneous automated coding Post-service individualized coding Diagnostic imaging Interventional radiology

32 Study Requested Request Generated CPT Code Transferred Performed & Dictated Billing Office QA!

33 Study Requested Performed & Dictated Coding by Professional Billing Office Manual Coder Certified Coder (RCC) Semi-Automated Natural language processing ±Coder

34 Transcribed Report Procedure Performed Provisional Coding by IR Coding by Professional Billing Office

35 CMS 1500

36 CMS 1500 (the fine print)

37 Cases: Documentation Extremity radiography Chest radiography Abdominal CT

38 Documentation Where physicians make a difference If it wasn t documented, it didn t happen!

39 Ankle Radiography Comment: There are no previous studies for comparison. No fracture, dislocation or bone destruction is observed. No soft tissue swelling is present. Impression: Negative for fracture.

40 Ankle: Problems No indication (no documented medical necessity). No mention of views: two views $ minimum 3 views $7.92

41 Chest Radiography Clinical History: Hip pain. Comment: Reference is made to examination from last year. The cardiac and mediastinal contours remain within expected limits. The lungs and pleural spaces are clear. The bones are within expected limits. Impression: No acute abnormality.

42 Chest: Problems Clinical history does not support medical necessity. No mention of views: single view $ frontal & lateral $ two views w/ obliques $14.19

43 Abdominal CT Clinical History: Flank pain, possible mass on IVP. Technique: Thin cut spiral renal imaging was performed followed by spiral imaging throughout the entire abdomen. Reference is made to IVP from last month. Comment: The lung bases are clear. No pleural effusions are present. The liver, spleen, pancreas and adrenal glands are within expected limits. No bowel or mesenteric abnormalities are present. The abdominal aorta is not dilated. No lymphadenopathy is present. No solid or cystic renal mass is seen to correspond to the IVP abnormality. This is believed to simply reflect persistent fetal lobulation. Impression: Negative for renal mass.

44 CT: Problems No description of contrast technique CT abdomen without $ CT abdomen with $ CT abdomen both $64.19

45 Summary Physician payment systems are often perceived as complex and burdensome. To get paid? Play the game. Don t play? Volunteer or defendant? Success is truly a team effort. Do your part: Buy in!