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
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.
This is a Real Case $1,600,000 Settlement Agreement. No Admission of Guilt.
And So is This $2,500,000 Settlement Agreement. No Admission of Guilt.
Who Will Be Next?
Agenda Concepts of compliance Basic coding definitions Fundamental coding rules Rules of medical necessity Actual compliance models Case studies: documentation
Fraud and Abuse Prosecution Fraud and abuse identification and prosecution a priority for: CMS and OIG of HHS Individual Medicare carriers Definitions important
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
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: 184-192.
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: 734-740.
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: 59434-59452.
Compliance Plan We care about correct reimbursement Regimented billing QI program Stated plan Compliance officer Due diligence Ongoing audits, education, training and improvements
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
Get Certified! OIG model compliance plan for physician practices encourages coder certification Larger practices have higher burdens
Definition: CPT aka CPT-4 or CPT-2004 Current Procedural Terminology WHAT service was rendered
Basics: Category I CPT Codes 10000-60000 70000 80000 90000 procedures radiology laboratory medicine medicine
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.
Basics: CPT Service code examples 71020 = frontal and lateral chest 36569 = adult PICC line placement
Definition: ICD aka ICD-9-CM International Classification of Diseases WHY a service was rendered
Basics: ICD Diagnosis code examples extremity atherosclerosis w/ ulceration = 440.23 pneumonia, aspiration, due to food = 507.0 rule out (whatever) =???
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-01-144, effective January 1, 2002
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-01-144, effective January 1, 2002
CXR Diagnosis Coding 1 Order: cough and fever Exam: pneumonia ICD-9: pneumonia
CXR Diagnosis Coding 2 Order: cough and fever Exam: negative ICD-9: cough, fever
CXR Diagnosis Coding 3 Order: rule out pneumonia Exam: pneumonia ICD-9: pneumonia
CXR Diagnosis Coding 4 Order: rule out pneumonia Exam: negative ICD-9:???
Medical Necessity Various definitions Clinical information must support the need for the service provided.
Medical Necessity: Example CT abdomen with contrast (72193) YES: appendicitis 540.0-540.9, 541, 542 NO: headache 784.0 ICD-CPT concordance = medical necessity
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
Signature here means you can bill the patient
Correct CPT Coding: Systems Contemporaneous automated coding Post-service individualized coding Diagnostic imaging Interventional radiology
Study Requested Request Generated CPT Code Transferred Performed & Dictated Billing Office QA!
Study Requested Performed & Dictated Coding by Professional Billing Office Manual Coder Certified Coder (RCC) Semi-Automated Natural language processing ±Coder
Transcribed Report Procedure Performed Provisional Coding by IR Coding by Professional Billing Office
CMS 1500
CMS 1500 (the fine print)
Cases: Documentation Extremity radiography Chest radiography Abdominal CT
Documentation Where physicians make a difference If it wasn t documented, it didn t happen!
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.
Ankle: Problems No indication (no documented medical necessity). No mention of views: 73600 two views $7.21 73610 minimum 3 views $7.92
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.
Chest: Problems Clinical history does not support medical necessity. No mention of views: 71010 single view $8.30 71020 frontal & lateral $10.15 71022 two views w/ obliques $14.19
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.
CT: Problems No description of contrast technique 74150 CT abdomen without $54.41 74160 CT abdomen with $58.30 74170 CT abdomen both $64.19
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!