Coding and Compliance

1. New and Reappointment Review for Radiologists Coding and Compliance

2. Course Objectives The purpose of this course and its follow-on test is to provide radiologists who are being credentialed by UNC Hospitals with important information on three issues…

3. Course Objectives • Why coding and compliance is important to you and your practice • Coding and documenting radiology services • Teaching physician (TP) rules. In order to bill for services when working with residents and fellows, the teaching radiologist must abide by federal and state laws and regulations

4. Why coding and complianceis important to you and your practice

5. Reimbursement • Doing only what is medically necessary • Documenting what you do • Billing what you document Providing good care while billing accurately and confidently requires: Understanding and applying coding and compliance conventions can improve the level of reimbursement for UNC P&A practices as well as the quality of the medical record documentation.

6. Why Compliance • Residents are paid through the hospital by Part A Medicare. Medicare pays a portion of the residents’ salaries based on the proportionate share of Medicare at the teaching hospital. • Teaching physicians are paid by Part B Medicare on a fee-for-service basis. • The government, through Medicare, will pay for both resident and TP services if both participate. If the TP does not participate in a given patient service, the TP cannot bill. • If documentation does not indicate the participation of the teaching radiologist it is not billable to Medicare. Medicare has recouped and fined practice plans where this documentation was lacking.

7. Why Compliance • Beginning in December, 1995 the University of Pennsylvania, Thomas Jefferson, Pittsburgh, UT San Antonio, South Carolina, Virginia, the U Cal System, Chicago and seven or eight other schools of medicine have paid fines and penalties ranging from $2M to $30M. • The University of Washington recently underwent a criminal investigation and settled with the federal government for $35 M in addition to paying $26 million in legal defense costs. • Since July 2002 , there have been at least two whistle blower faculty practice settlements and in January 2003, the Cleveland Clinic settled with Medicare for $4M.

8. Coding and Documenting Radiology Services

9. Procedures requiring supervision 75660 Angiography, external carotid, unilateral, selective, radiological supervision and interpretation Some radiology CPT code descriptions refer specifically to supervision of the imaging such as in the following example: Procedures which include the notation, “supervision and interpretation” are known as S&I codes and include 2 distinct parts: • personal supervision of the radiologic portion of a procedure • the interpretation of the findings.

10. Procedures requiring supervision (con’t) • Physician Presence: Radiologic S&I codes are used to describe the personal supervision of the radiologic portion of a procedure and the interpretation of the findings. • Billing for the supervision: the physician must be present during its performance. In order to bill Medicare, it must be the teaching physician. • Billing for interpretation: interpretation may be performed later by another physician. For example, a radiologist is not usually present when an intraoperative angiogram is performed thus is only eligible to bill the code with a –52 modifier indicating a reduced service, e.g., the interpretation only. The surgeon may also bill the code with the –52 modifier to indicate performance of the supervision component of the service. • Only one interpretation of an imaging study is billable.

11. Unordered Tests & Procedures • If the diagnostic radiologist determines: • that an ordered test is “clinically inappropriate or suboptimal” (e.g., an MRI should be performed instead of a CT scan because of the clinical indication) OR • that the results of the ordered test are normal and an additional test should be performed (e.g., a renal sonogram was normal and based on the clinical indication, the interpreting physician believes an MRI will reveal the diagnosis) Additional tests may NOT be performed without a new or additional order from the treating practitioner.

12. Unordered Tests & Procedures (cont’d) Additional Diagnostic Test Exception If the testing facility cannot reach the treating physician/practitioner to change the order or obtain a new order and documents this in the medical record, then the testing facility may furnish the additional diagnostic test if all of the following criteria apply: • The testing center performs the diagnostic test ordered by the treating physician/practitioner; • The interpreting physician at the testing facility determines and documents that, because of the abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary; • Delaying the performance of the additional diagnostic test would have an adverse effect on the care of the beneficiary; • The result of the test is communicated to and is used by the treating physician/practitioner in the treatment of the beneficiary; and • The interpreting physician at the testing facility documents in h/her report why additional testing was done. • EXAMPLE: (a) The last cut of an abdominal CT scan with contrast shows a mass requiring a pelvic CT scan to further delineate the mass; (b) a bone scan reveals a lesion on the femur requiring plain films to make a diagnosis.

13. Modifiers • 26 - Professional Component:Imaging studies are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier 26 to the usual procedure number. The 26 modifier is NOT used when the CPT code describes the procedure as being the professional component. • TC - Technical Component. At UNC, the hospitals always bills for the technical component; however, in other practices outside UNC a charge may be made for the technical component alone. Under those circumstances, adding modifier TC to the usual procedure number identifies the technical component charge. • 52 - Reduced Service (e.g., the code calls for two views but only one is performed.) • LT and RT modifiers indicate which side of the body was viewed Note: use two units if the same side is repeated.

14. Interventional Radiology Documentation • Document what you do: • The reason for the service is a required element of the documentation • If radiological guidance is employed in the procedure, please specifically record that in your procedure note in order to bill additionally for that portion of the service • Evaluation and management (E&M) services (inpatient or outpatient visits) require specific detail to be included. If you bill for E&M services, please be sure you know the regulations, summarized at: http://www.med.unc.edu/credentialing/OnlineRecredCF050503.pps

15. Interventional Radiology-Consult Codes • Consultation codes are better paid than other E&M codes and require specific conditions and documentation • Use when expert opinion or advice is requested by an appropriate source involved in that patient’s care • Does not include patients “referred for management of a condition” or self-referred • Use outpatient consultation codes only one time per request, subsequent visits are established patient visits • A consulting physician may initiate diagnostic and/or therapeutic services at the same visit and the initial visit remains a consultation • Written or verbal request must be documented in the rendering physician’s note and the consultant’s opinion communicated by written report to the requesting physician

16. Interventional Radiology-Consult Codes Documentation of a consultation request must be clearly stated in the note: WRONG: Mr. Patient referred by Dr. Jones for management of GERD symptoms. RIGHT: “Mr. Patient is seen in consultation at the request of Dr. Jones for evaluation of abdominal pain.” Please be sure to document that a copy of the note (cc: Dr. Jones) is to be sent to the requesting physician.

17. Diagnosis coding • Tests ordered due to signs and/or symptoms • If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis. • If the diagnostic test did not provide a diagnosis or was normal, the interpreting physician should code the sign(s) or symptom(s) that prompted the treating physician to order the study.

18. Diagnosis coding • Tests ordered without a usable diagnosis or signs/symptoms • If the results of the imaging study are normal or non-diagnostic, and the referring physician records a diagnosis preceded by words that indicate uncertainty (e.g., probable, suspected, questionable, rule out, or working), then the interpreting physician should not code the referring diagnosis. Rather, the interpreting physician should report the sign(s) or symptom(s) that prompted the study. • On the occasion when the interpreting physician does not have diagnostic information as to the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient’s medical record if it is available. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician.

19. Diagnosis coding • Tests ordered for screening • When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness or injury, report the screening code (CPT “V” code, a supplementary series of codes for occasions when circumstances other than disease or injury are recorded as “diagnoses” or “problems”) as the primary diagnosis code. • Any condition discovered during the screening should be reported as a secondary diagnosis

20. 3. Teaching physician (TP) rules—supervision of residents and billing Medicare and Medicaid

21. TP Attestations - Interpretations • Medicare pays for the interpretation of diagnostic tests if the interpretation is performed by or reviewed by a teaching physician. • If a resident prepares and signs the interpretation, the teaching physician must indicate that he or she has personally reviewed the image and the resident's interpretation and either agrees with it or edits the findings. • The resident may not document the participation of the teaching physician • Cosignature of a resident's interpretation alone is not sufficient for billing Medicare.

22. Supervision and attestation for procedures • Minor procedures of <5 minutes • Must be present the entire time to bill • Resident may document presence, TP co-signature • For other procedures, the TP must be present during critical and key portions & immediately available throughout • TP decides what portions are key • If present entire time, the resident’s note can attest to that • If present for key portions only, TP must document extent of involvement • Procedures which include supervision and interpretation (S&I) in the CPT code description • Must be present the entire time to bill • Resident may document presence, TP co-signature required

23. North Carolina Medicaid Requirements • Medicaid requires that the TP be "immediately available" to the resident and patient and use "direct supervision" for procedures. Direct supervision does not necessarily mean that the TP must be present in the room when the service is performed. • The degree of supervision is the responsibility of the TP and is based on the skill, level of training and experience of the resident as well as the complexity and severity of the patient's condition. Written documentation in the medical record for Medicaid patients must clearly designate the supervising physician and be signed by that physician.

24. Where To Get Help • www.med.unc.edu/compliance/ • UNC P&A Professional Coder, Radiology • Amanda Holyfield, CPC, 843-4138 • School of Medicine Compliance Office 843-8638 • Heather Scott, CPC, Compliance Officer • Keishonna Carter, Compliance Review Analyst • Nirmal Gulati, CPC, Compliance Auditor • Lateefah Ruff, Office Assistant • Confidential Help Line 800-362-2921 • AMA CPT Manual