The Treasure Hunt—Keys to Unlocking Radiology Reimbursement PAYMENT

1. The Treasure Hunt—Keys to Unlocking Radiology Reimbursement PAYMENT Walt Blackham, MS, RCC Radiology Business Management Association, RBMA

2. THE ROLE OF CODING Communication between • You, the healthcare provider) and the • Payer • The Patient • The insurance Company • Some other third party

3. Correct Coding: Why Bother?

4. THE ROLE OF CODING • Proper coding is the initial (and most important) step in the process of obtaining correct payment for the services you provide. • Proper coding is the first building block for Corporate Compliance

5. THE ROLE OF CODING • Coding is a unique language

6. THE ROLE OF CODING CPT 4 • Current Procedural Terminology • AMA code set for physician services • Describes what you did • Under HIPPA CPT is the uniform coding set • CPT 5 in development

7. THE ROLE OF CODING CPT • 5 digit alphanumeric code set • Category 1 from 00100-99602 • Category 3 - 0016T-0170T • 2 digit modifiers • “…indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.”

8. THE ROLE OF CODING CPT • Rules of procedure coding • “Select the name of the procedure or service that accurately identifies the service performed.” • “Do not select a CPT code that merely approximates ……”

9. THE ROLE OF CODING CPT • Rules of procedure coding • “If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code. “

10. New CPT Codes • Application from the AMA with clinical vignettes • Usually handled thru the medical professional societies • CPT Advisory Committee • CPT Editorial Panel • AMA/Specialty RVS Update Committee (RUC)

11. Level II HCPCS • Medicare alphanumeric codes for; • Procedures e.g. digital mammography • Non-Ionic Contrast • Radiopharmaceuticals • Other drugs and codeable supplies

12. THE ROLE OF CODING ICD-9-CM • Diagnosis codes describe why you did the particular CPT code

13. THE ROLE OF CODING ICD-9-CM • 3 to 5 digit alphanumeric codes • 001.0 through 999.9 • V01.0 through V86.1

14. THE ROLE OF CODING For proper ICD-9 Coding code: A. Highest Level of Specificity Use 4th and 5th digits when available B. Highest Level of Certainty Code positive results if relevant to the encounter

15. THE ROLE OF CODING • As specified in §4317(b) of the Balanced Budget Act (BBA), referring physicians are required to provide diagnostic information to the testing entity at the time the test is ordered.

16. THE ROLE OF CODING • PAIN!!!!!! • The Central Office for ICD-9-CM has sent a letter in stating that The Cooperating Parties of ICD-9-CM (AHA, AHIMA, CMS, NCHS) “..agreed that since the x-ray was specific to a site (in this case, the neck), the more specific code for “neck pain” or 7231, Cervicalgia, may be assigned as the reason for the x-ray.”

17. THE ROLE OF CODING • According to the *Official Guidelines for Coding and Reporting* (Section IV), in the outpatient setting, diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ or ‘working diagnosis’ are not coded.  Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

18. THE ROLE OF CODING • “These terms [‘consistent with,’ ‘compatible with,’ ‘indicative of,’ ‘suggestive of,’ and ‘comparable with’] fit the definition of a probable or suspected condition”

19. THE ROLE OF CODING “On the rare 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.”

20. DOCUMENTATION MODEL • Model based on ACR Practice Guideline for Communication of Diagnostic Imaging Findings • Demographics • Patient Identifiers, name, ID # • Facility Name / location • Referring Physician name • Date of Exam • Etc.

21. DOCUMENTATION MODEL • Name or type of Examination • Use terminology as listed in CPT • Plain films - specify number of views • CT & MR - without, with or with and without contrast SPECIFY WHICH FOR EACH EXAMINATION • Nuclear Medicine - CPT name not radiopharmaceutical name Note: If a combination of services are performed in the same session, each should be separately dictated and documented in the written report

22. DOCUMENTATION MODEL • Time of Exam Where Appropriate • Multiple portable chests on the same day

23. DOCUMENTATION MODEL • Reason for the Exam Relevant Clinical Indicator • Cannot use rule-out or probable diagnosis for billing • For billing must have signs and symptoms, for example, pain or injury if exam is negative • However, The MORE clinically information the better.

24. DOCUMENTATION MODEL • Body of Report • Impression or Conclusion • Except if report is very brief • Rendering radiologist’s name

25. The Radiology Report • If you can’t read it, you can’t code it.

26. Questions? Walter C. Blackham, MS, RCC President and CEO Specialty Medical Services, Inc. 221 West 8th Street Lorain, OH 44052-1817 Walt@SPMEDS.com 440.245.8010 Ext. 10