Radiology Compliance Question of the Week
Archive
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September 29, 2008
Question:
I need help related to hospital billing and the APC system. I have a question
concerning hospital reimbursement for radiology procedures: How can I find
out what kind of payment a procedure will receive from Medicare?
Answer:
In order to determine what is paid separately and what is bundled under
the hospital outpatient prospective payment system (OPPS), you must know
all of the codes submitted for billing as well as the status indicators
(SIs) of these codes. Depending upon the SI, the payment for the service(s)
in question may or may not bundle or be reduced into other services/procedures
performed on the same day of service on the Medicare outpatient.
The current 2008 SIs (effective through December 31, 2008) can be found
at
http://www.cms.hhs.gov/HospitalOutpatientPPS/Downloads/CMS1392P_Addendum_D1.pdf
You also will want to check Addendum B, which lists the national OPPS payment rates, at http://www.cms.hhs.gov/HospitalOutpatientPPS/AU/list.asp#TopOfPage. In the left column, scroll down to "Addendum A and B Updates." Under the first column ("Release Date"), look for the most recent date for the year. For example, at this writing, the most recent date for Addendum B is July 2008.
You should look up the SI in Addendum B and check the meaning of the SI to determine how you will be paid. For example, the SI of "S" (significant procedure) means "significant procedure, not discounted when multiple." There will never be any payment reduction to any codes with the SI of "S," no matter what other code is reported with them.
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September 22, 2008
Question:
If an angioplasty is performed in one vessel and the results were sub-optimal
and a stent was deployed in this same location in the same vessel, can both
be coded and billed?
Answer:
In August 2008, the Centers for Medicare & Medicaid Services (CMS) announced that it would "temporarily rescind" a restrictive policy that has, since October 1, 2007, prevented providers from reporting more than one non-coronary angioplasty, stent or atherectomy performed in the same vessel at the same clinical setting. The policy below will be published on October 1, 2008, in version 14.3 of the National Correct Coding Initiative Policy Manual for Medicare Services (Chapter V-Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems, CPT Codes 30000-39999) as well as the online version.
"D. Cardiovascular System
16. When percutaneous angioplasty of a vascular lesion is followed at the
same session by a percutaneous or open atherectomy, generally due to insufficient
improvement in vascular flow with angioplasty alone, only the most comprehensive
atherectomy that was performed (generally the open procedure) is reported
(see sequential procedure policy, Chapter I, Section M)."
For the home page for the national correct coding initiative (CCI) edits, go to http://www.cms.hhs.gov/NationalCorrectCodInitEd/.
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September 15, 2008
Question:
Is it appropriate to report a lower extremity arteriogram, unilateral,
to determine the use of an angioseal device? (This is a limited lower extremity
arteriogram performed at the end of a head/neck arteriogram procedure or
cardiac catheterization.)
Answer:
The National Correct Coding Initiative (CCI), Chapter 11, says the following: "Placement of an occlusive device such as an angioseal or vascular plug into an arterial or venous access site after cardiac catheterization or other diagnostic or interventional procedure should be reported as HCPCS code G0269 [placement of occlusive device into either a venous or arterial access site, post surgical or interventional procedure (e.g., angioseal plug, vascular plug)]. Provider should not report an associated imaging code such as CPT code 75710 or HCPCS code G0278."
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September 8, 2008
Question:
Regarding CTAs, does image post processing include only 3D reformats?
Answer:
No, CTA reconstructions can be 2D or 3D, but the key is the image post-processing must be defined in the physician's report.
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September 1, 2008
Question:
When a radiologist performs a duplex scan, does he have to state both
spectral and color in his dictation? If spectral is not documented, must
the service be down coded?
Answer:
Per CPT language (which is now consistent with what the American College of Radiology [ACR] has said previously), the American Medical Association states the following "Evaluation of vascular structures using both color and spectral doppler is separately reportable." "However, color doppler alone, when performed for anatomic structure identification in conjunction with a real-time ultrasound examination, is not reported separately." In our opinion, if both components are not defined, the non-invasive code should not be assigned.
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August 25, 2008
Question:
The hospital that my radiologists read for has asked what procedure codes
would be utilized in a new neurointerventional suite they are planning using
a biplane piece of equipment. Any ideas would be appreciated.
Answer:
There are no special codes for what you describe above. The CPT codes are not based upon how the study was done, but on what was imaged. The only thing "special" that may end being done is true 3D post-processing of angiography data, but physicians must also make sure they adhere to the documentation requirements for these codes in order to use them (see codes 76376 or 76377 in the CPT manual).
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August 18, 2008
Question:
I have a question related to an MRI of the coccyx ordered by a referring
physician. Should a code for the pelvis or lumbar spine be used for this?
We have some differences of opinion. Is there any documentation for this?
Answer:
Here's what the American College of Radiology (ACR) says: "For MR studies of the sacrum or SI joints, current ACR directives state that this procedure not be defined by the unlisted code 76498, but by the anatomic site specific code for MRI of the pelvis. Codes 72195-72197 may also be used to define MRI of the sacral plexus."
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August 11, 2008
Question:
Can you explain the 2009 proposed rule related to all radiology offices
having to be registered as IDTFs?
Answer:
In the 2009 proposed rule for the Medicare physician fee schedule (MPFS),
the Centers for Medicare & Medicaid Services (CMS) proposed that all
physician and non-physician practitioner groups furnishing diagnostic testing
services (except diagnostic mammography services) enroll as an independent
diagnostic testing facility (IDTF) and be subject to most (but not all)
of the IDTF performance standards.
Those that that do not enroll as an IDTF may have their claims for diagnostic
testing services denied or have their Medicare billing privileges revoked
for the proposed MPFS rule, go to http://edocket.access.gpo.gov/2008/pdf/E8-14949.pdf.
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August 4, 2008
Question:
Does the new Medicare law make any changes to the way radiopharmaceuticals
are paid under the hospital OPPS?
Answer:
Yes, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (HR 6331), which Congress passed on July 16, does include a change. Here's how it goes.
Between January 1 and July 1 of 2008, therapeutic radiopharmaceuticals and brachytherapy sources were paid under hospital outpatient prospective payment system (OPPS) status indicator (SI) "H" (defined as "separate cost-based non-pass-through payment"). Between July 1 and July 15, 2008, they were paid under the SI of "K" (defined as "paid under OPPS; separate ambulatory payment classification [APC] payment")-a reduced rate from SI of H. As a result of the MIPAA provision, between July 1, 2008, and January 1, 2010, Medicare will base hospital OPPS rates on the SI of H.
HR 6331 did not address diagnostic radiopharmaceuticals. But in the 2009 proposed hospital OPPS, the Centers for Medicare & Medicaid Services (CMS) indicated that it would not change the way it pays for diagnostic radiopharmaceuticals and contrast agents. Medicare will continue to bundle payments for these supplies into the APC of the major service or procedure performed.
HR 6331 can be found at http://thomas.loc.gov/. Under "Search Bill Text," type HR 6331, and select "Bill Number" under that entry.
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July 28, 2008
Question:
What would be the appropriate coding for placement of suprapubic catheter
with imaging and also subsequent catheter changes with imaging?
Answer:
For the placement, see the modality-specific image guidance code (i.e., 77012-for CT, 76942-for ultrasound, and 77002-for fluoroscopy) and the surgical code of 51102. For the exchange of a cystostomy tube, see 75984 and 51705 or 51710.
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July 21, 2008
Question:
My question relates to computed tomography angiography (CTA). If we have
a workstation (vitrea) that automatically does the reconstructions and 3D
imaging, can we charge for the image post-processing CTA code? Or do we
have to reduce the charge to the body part with contrast only?
Answer:
Codes 76376 or 76377 cannot be charged separately with any CTA codes, according to CPT instructions found in the parenthetical notes following these codes.
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July 14, 2008
Question:
Can we bill computer-aided detection (CAD) with a breast MRI?
Answer:
Yes. If performed and documented, it is appropriate to also assign Category III code 0159T when performing breast magnetic resonance imaging (MRI).
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July 7, 2008
Question:
I have a question on the answer you gave about a patient signing an ABN
for a non-covered radiology procedure. Shouldn't the patient be told in
advance (before arriving for his appointment) that the study is non-covered?
Answer:
You are correct that the best scenario is for the treating physician to
issue the advance beneficiary notice (ABN ) before referring the patient
to the hospital or imaging center for the procedure. However, this is not
always what happens.
As the billing entity, the facility where the procedure is performed, and
which bills Medicare, is ultimately responsible for insuring that the beneficiary
is informed of his/her financial responsibility and Medicare's potential
non-coverage of the procedure. If the procedure to be performed is scheduled
through the radiology department, a process may be in place that allows
for the scheduler to alert the physician of the need for an ABN before sending
the patient. But for a non-scheduled walk-in procedure, there must be a
policy and procedure in place by which the facility completes the process
of validating medical necessity and, if indicated, issues the ABN. All policies
must take into account the patient that presents under emergent conditions
and establish the steps to be followed so that care is not delayed or prevented.
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June 30, 2008
Question:
What is Medicare's policy related to radiology services and the ABN in
the hospital outpatient setting? Is it required or not?
Answer:
In the hospital outpatient setting, a patient may arrive without a referral after normal business hours. For non-emergencies, he/she should be asked to sign an advance beneficiary notice (ABN). For urgent situations, registration staff must comply with the Emergency Medical Treatment and Labor Act (EMTALA) requirements. Briefly, this means that the hospital physician(s) must provide an appropriate medical screening exam and stabilize the patient before he/she is transferred to another facility or discharged to home.
As stated in last week's answer, the ABN is a big subject, and more about it can be found at http://www.cms.hhs.gov/BNI/. Note, particularly that a new form takes effect on September 1, 2008.
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June 23, 2008
Question:
I work in a radiologist's office. Are radiologists ever required to issue
an ABN to a patient?
Answer:
Generally, it is the treating physician who issues an advance beneficiary
notice (ABN) to the patient. However, sometimes a patient arrives for a
test and the registration staff discover (after checking the national and
local coverage determinations) that the payer won't cover the test for the
diagnosis listed on the referral.
In such cases, the ordering physician should be called to confirm whether
he/she really wants that test performed. Sometimes it's just a misunderstanding
or mistake in information transferred, but sometimes the treating physician
actually wants the test performed in spite of the lack of coverage.
In that case, the radiology office staff should ask the patient to sign the ABN before the service/procedure is started. This signed document allows you to bill the patient when the payment is denied. However, you may not bill the patient if the ABN was signed after the procedure was started.
The ABN is a big subject; more about it can be found at http://www.cms.hhs.gov/BNI/. Note, particularly that a new form takes effect on September 1, 2008.
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June 16, 2008
Question:
Can code 78811 be assigned when PET/CT is performed on an integrated system
(hardware fusion), and the CT is used for both attenuation correction and
anatomic localization?
Answer:
Per the CPT manual, code 78811 identifies positron emission tomography (PET) imaging; limited area (e.g., chest, head/neck). This code is used when a limited area PET imaging study such as the chest alone or neck alone are imaged and analyzed without anatomic localization. This code should not be used in the situation described above. Instead, select a code from the 78814-78816 range. These CPT codes describe the hardware fusion of PET and CT imaging when the CT is used for attenuation correction and anatomic localization only.
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June 9, 2008
Question:
What code should be assigned for a chest tube insertion under CT guidance?
Answer:
Depending on the reason the tube was inserted, see code 32422 or 32551. If a tunneled Pleurx catheter was inserted, see new code 32550 (guidance is 75989). For CT guidance, see code 77012 when assigning code 32422. For CT guidance when performing the tube placement for abscess drainage, empyema or hemothorax (32551), see 75989.
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June 2, 2008
Question:
Are there certain Doppler codes that are used for breast ultrasound and
pelvic ultrasound?
Answer:
Assuming the exam is medically necessary and documented per CPT guidelines, any of the non-invasive vascular codes could be chosen from for the anatomic area imaged.
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May 26, 2008
Question:
Can charges be submitted for Conray 60 that is used in the performance
of ERCP (endoscopic retrograde cholangiopancreatography)?
Answer:
Conray--an injectable, ionic, high osmolar contrast media agent--is defined by Level II HCPCS codes Q9958-Q9964. Depending on whether the hospital or physician incurs the expense for this, you may be able to submit a separate charge for it. For hospital billing (i.e., UB-04 claim form), report with revenue code 636.
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May 19, 2008
Question:
Do you know what the deadline is for becoming accredited to receive imaging
reimbursement from the payer United Healthcare?
Answer:
UnitedHealthcare (UHc) plans to require all facilities that perform diagnostic imaging to obtain appropriate accreditation by the third quarter of 2008 (July through September) in order to continue receiving reimbursements. The payer will notify imaging facilities 30 days before the program becomes effective in their areas. As long as the imaging site has submitted its application by its effective start date, it will be in compliance with the accreditation program. Those that have not applied for accreditation will not be eligible for reimbursement from UHc. Although other payers require imaging accreditation at the local or state level, UHc is the first to implement a national imaging accreditation program.
A complete list of CPT codes that fall under UHc's accreditation mandate
can be found at www.UnitedHealthcareOnline.com.
Use the search function and type "accreditation."
Look for a document entitled An Imaging Accreditation Overview, which
lists the codes that require accreditation and other important information.
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May 12, 2008
Question:
How should we charge if only the radiopharmaceutical was administered?
For example, if a patient was given the RP but he didn't return for the
scan or for whatever reason the imaging just was not done, is it proper
to submit a modifier with the RP alone?
Answer:
In addition to reporting the radiopharmaceutical, the recommendation is to also submit the CPT code for the procedure that was to be performed with the appropriate modifier (e.g., -52, -53). The rationale behind the assignment of the CPT code for the procedure also being used is that a nuclear procedure begins with the administration of the radioactive material.
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May 5, 2008
Question:
When doing a duplex scan, must radiologists state both spectral and color
in their dictation? If spectral is not documented, must the service be down-coded?
Answer:
According to the language that is now in the CPT code book (which is now consistent with what the American College of Radiology previously stated), "Evaluation of vascular structures using both color and spectral Doppler is separately reportable." "However, color Doppler alone, when performed for anatomic structure identification in conjunction with a real-time ultrasound examination, is not reported separately." In our opinion, if both components are not defined, the non-invasive code should not be assigned.
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April 28, 2008
Question:
Is it appropriate to assign more than one code for a kidney study?
Answer:
We do not recommend using more than one code from the 78700-78725 series for billing a kidney study. Choose the single highest-valued code based on the procedure performed. Note, however, that the national correct coding initiative (CCI) does currently allow, with a modifier 59, some of the CPT code combinations for 78700-78725.
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April 21, 2008
Question:
If a GI doctor inserts the tube and the radiologist is only there to supervise/perform
fluoro, which code do we assign?
Answer:
As the description of all the new gastrointestinal (GI) tube codes include fluoroscopy, the real question is whether this code can be modified to include multiple physician involvement. A review of the 2008 Medicare physician fee schedule shows that codes 49440-49442 carry the status of "0," which means that these codes cannot be assigned modifier 62 or 80 when more than one provider is involved.
In this situation, it may be possible for the radiologist to submit either code 76000 or 76001 for his or her involvement. Note that these codes are for <1 hour (76000) or >1 hour (76001). At no time should a single provider submit both the 494XX codes and the 7600X codes.
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April 14, 2008
Question:
What are the appropriate codes to use for magnetic resonance cholangiopancreatography
(MRCP) if ordered alone, as well as MRCP ordered in conjunction with an
MRI of the abdomen?
Answer:
The online July/August 2006 issue of ACR (American College of Radiology) Coding Source included the following answer to a similar question:
"If imaging of the abdomen is performed concurrently with a … MRCP study, it is appropriate to report one of the MRI of the abdomen codes (74181, 74182, or 74183) plus a 3-D reconstruction code (76376 or 76377). An additional MRI of the abdomen code should not be reported, as performance of an additional sequence or two would be considered part of the base procedure code. A … MRCP study includes MIP cholangiographic images, as well as any axial and/or coronal abdominal MR cross-sectional images."
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April 7, 2008
Question:
Does Medicare pay for code 78890--generation of automated data; not to
exceed 30 minutes?
Answer:
Medicare has stated that for services provided by either a facility or physician, they will not make separate payment for services defined by CPT code 78890 or 78891 as these are considered to be packaged or bundled into the primary procedure. However, other third-party payers may reimburse for this work so be certain to clarify local payer requirements.
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March 31, 2008
Question:
How should the radioactive material used in a hospital for lung scanning
be charged to Medicare?
Answer:
Be certain to submit a separate charge for each radiopharmaceutical utilized. Some payers may ask you to submit an invoice when billing for these items. All parties (i.e., physicians, hospitals, etc.) will need to identify the diagnostic radiopharmaceutical(s) with appropriate HCPCS Level II A or C codes. (HCPCS "C" series codes are only for Medicare outpatient hospital billing.)
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March 24, 2008
Question:
Can computer-aided detection (CAD) be billed with a breast MRI?
Answer:
Yes. If performed and documented, it is appropriate to also assign Category III code 0159T when performing breast manetic resonance imaging (MRI).
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March 17, 2008
Question:
A gastric emptying exam for both liquids and solids was requested and
performed on two separate days--one for liquids and one for solids. The
HMO denied the second study stating the exams are usually performed on same
day, same session. Please comment on this protocol.
Answer:
The most common study currently performed is a dual isotope 99mTc and In-111 study, and this is what payers are used to. If you do not have medium energy colluminators, you may not be able to do this procedure. It is still acceptable to do a two- day protocol, and you can check procedure guidelines posted under practice management at https://www.snm.org for the different protocols. Also, the SNM (formerly Society for Nuclear Medicine) gastrointestinal counsel just published updated guidelines so be sure you get the new ones by contacting Zach at the SNM (703-708-9000) if you can not locate them. As for the coding, try using any modifiers to and supply the separate reports of both.
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March 10, 2008
Question:
Our facility routinely replaces what are considered G-J Tubes, can both
of the following be charged in these cases?
49450 Replace g/c tube perc
49451 Replace duod/jej tube perc
Answer:
No. The 2008 CPT code book was updated this year to cover these procedures.
Based upon the new codes and descriptions, you would use the following surgical
code only.
49452 Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic
guidance including contrast injection(s), image documentation and report
For blood count, spun microhematocrit, use CPT 85013 (blood count; spun hematocrit) in conjunction with CPT 78122, if performed.
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March 3, 2008
Question:
Can you provide information about code 78122--whole blood volume determination,
including separate measurement of plasma volume and red cell volume?
Answer:
In this procedure, blood volume analysis is based on the concept of the indicator dilution technique, whereby a tracer substance (e.g., albumin I-131) is mixed into an unknown volume. An identical amount of tracer is placed into a known volume. By comparing the concentration of the indicator between the known and unknown volumes, an exact measurement of the unknown volume can be obtained.
For blood count, spun microhematocrit, use CPT 85013 (blood count; spun hematocrit) in conjunction with CPT 78122, if performed.
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February 25, 2008
Question:
My question relates to code 78195-lymphatics and lymph nodes imaging.
If the lymphoscintigraphy imaging includes SPECT imaging, is this the correct
code to assign?
Answer:
For SPECT alone or with planar imaging with or without flow, you should assign CPT 78803--radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic. The term "distribution" in this code allows it to be used for broader indications outside of the original, more restrictive "tumor imaging" language.
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February 18, 2008
Question:
Regarding CTAs, does image post-processing include only 3D reformats?
Answer:
No. Computed tomographic angiographic (CTA) reconstructions could be 2D or 3D, but the key is that the image post-processing must be defined in the physician's report.
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February 11, 2008
Question:
When billing a nuclear medicine procedure, does Medicare require that
a radiopharmaceutical code be included on the claim?
Answer:
Yes. As of January 1, 2008, claims for nuclear medicine procedures that do not include a HCPCS Level II radiopharmaceutical code will be returned. On January 15, the SNM (formerly the Society of Nuclear Medicine) posted a "hospital billing alert" about this topic. For this announcement, go to http://www.snm.org/index.cfm?PageID=7241&RPID=10.
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February 4, 2008
Question:
How does the payment received by hospitals for diagnostic radiopharmaceuticals
differ from the Medicare physician fee schedule payment?
Answer:
In 2008, the payment received by hospital outpatient departments for diagnostic radiopharmaceuticals will be bundled with the major procedure performed. On January 1, 2008, the Centers for Medicare & Medicaid Services (CMS) implemented an outpatient code edit requiring hospital outpatient claims paid under the outpatient prospective payment system (OPPS) with a 78xxx CPT procedure code to be returned to provider (RTP) if a diagnostic radiopharmaceutical is not billed on the same claim as the major nuclear medicine procedure. CMS is implementing this edit to ensure hospitals are billing for radiopharmaceuticals.
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January 28, 2008
Question:
When doing a duplex scan must radiologists state both spectral and color
in their dictation? If spectral is not documented, must the service be down-coded?
Answer:
According to the language that is now in the CPT code book (which is now consistent with what the American College of Radiology previously stated), evaluation of vascular structures using both color and spectral Doppler is separately reportable. However, color Doppler alone, when performed for anatomic structure identification in conjunction with a real-time ultrasound examination, is not reported separately. In our opinion, if both components are not defined, the non-invasive code should not be assigned.
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January 21, 2008
Question:
I found the answer to last week's question confusing. Also, Transmittal
79, the reference you gave, has been rescinded. Can you please clarify these
issues?
Answer:
You are correct that the Centers for Medicare & Medicaid Services (CMS) has rescinded Transmittal 79. On Friday, January 11, CMS issued Transmittal 80 to replace that transmittal. (For that transmittal, go to http://www.cms.hhs.gov/transmittals/downloads/R80BP.pdf.) It contains most of the same information as was in Transmittal 79 except Section 80.6.2, which covered the "treating physician's or practitioner's ordering of diagnostic tests." The subsequent sections have been renumbered. However, as before, the rules discussed in Transmittal 80 relate only to "testing facilities" (i.e., not to hospitals).
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January 14, 2008
Question:
Our group has a hospital administrator insisting that our radiologists
need an amended order from the referring doctor to change or add a study.
Have there been changes to Section 15021 of the Medicare Carriers Manual
on hospital radiologists?
Answer:
The rules outlined in Section 15021 related to ordering diagnostic tests do not apply to hospitals. This is a very common misconception among hospital administrators and even hospital radiologists. You will want to download Transmittal 79 (change request 5743, October 25, 2007) at http://www.cms.hhs.gov/transmittals/Downloads/R79BP.pdf, which will provide you with all the information you need to respond to the hospital administrator. Also, be sure to ask the administrator to provide you with the Medicare guideline that requires a radiologist to obtain an amended order from the referring doctor.
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January 7, 2008
Question:
If a radiologist determines that, because of the clinical indication,
an MRI should be performed instead of the CT scan ordered by the treating
physician, can she perform it without another order?
Answer:
Section 80.6.3 of Chapter 15 of the Medicare Benefit Policy Manual addresses
the times when the interpreting physician, which includes radiologists and
cardiologists, determines that a different diagnostic radiology test is
clinically appropriate and should be performed. In the case you describe,
the test may not be performed until the
treating physician issues a new order.
Here's another example of when an order from the treating physician must
be received before an unordered diagnostic test is performed. The treating
physician orders a renal sonogram, and the results were normal. Based on
the clinical indication, the radiologist believes an MRI will reveal the
diagnosis.
Note that, unless specified, the above guidance and the sections covered by the transmittal provided below are not applicable in a hospital setting.
See Transmittal 79 at http://www.cms.hhs.gov/transmittals/downloads/R79BP.pdf for more on the above topic.
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December 31, 2007
Question:
Our pain management specialist performs a planned intercostal nerve injection of an anesthetic agent by four separate injections under fluoroscopic guidance: How is this best coded? Can we charge for four 64420 (intercostal nerve, single) or 64421 (intercostal nerves, multiple)?
Also, should we use 77002 for needle placement injection under fluoroscopic
guidance x 1 or 77002 x 4 for each separate injection?
Answer:
CPT 64420 is a component of 64421. For multiple intercostal nerve injections, report 64421 once and also report 77003 once (fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures).
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December 24, 2007
Question:
One of our radiologists does not dictate the quantity or type of injected
contrast in his reports. This information can be found elsewhere (tech notes,
etc). I have tried to convince him that this information should be in the
report, and we should not rely on the other documents, but I am afraid my
comments are falling on deaf ears. Should the contrast type and quantity
be contained within the report itself? If yes, is there something in writing
that would lend some to my argument?
Answer:
American College of Radiology (ACR) guidelines state the following: "The report should include a description of the studies and/or procedures performed and any contrast media (including concentration, volume, and route of administration when applicable), medications, catheters, or devices used, if not recorded elsewhere. Any known significant patient reaction or complication should be recorded."
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December 17, 2007
Question:
PA and lateral views of the chest were obtained as well as bilateral decubitus
views of the chest. The hospital put through codes 71020 and 71035 twice.
I want to charge a chest complete four view. Please give reason on who is
right and why.
Answer:
Actually, either method could be viewed as correct. CPT does provide for use the code 71030--radiologic examination, chest, complete, minimum of four views. CPT also shows the following options that identify the services rendered: 71020--radiologic examination, chest, two views, frontal and lateral and 71035--radiologic examination, chest, special views (e.g., lateral decubitus, Bucky studies). According to Medicare, modifiers 50, RT, or LT may not be used when assigning code 71035. If billing both 71020 and 71035, each special view is coded separately. We would suggest you bill with units and not any of the modifiers previously listed. Other payers may not follow Medicare on this, so check with yours.
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December 10, 2007
Question:
If a screening study is performed and a definitive diagnosis results,
should we report the procedure with a screening diagnosis code or with the
definitive diagnosis code?
Answer:
According to the May-June 2007 ACR Radiology Coding Source, one of the screening ICD-9 "V" codes should be used--for example: breast (V76.0-V76.19), prostate (V76.44), thyroid disorder (V77.0), osteoporosis (V82.81). If a definitive diagnosis is made, assign one of the screening "V" codes, and report the definitive diagnosis as secondary. For more information about the assignment of ICD-9-CM diagnosis codes, see the Official ICD-9-CM Coding Guidelines at http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm.
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December 3, 2007
Question:
Did CMS finalize its plan for packaging radiology services?
Answer:
CMS has finalized its proposal to extend the current Medicare packaging approach to include the following “supportive ancillary services”: Guidance services, image-processing services, intraoperative services, imaging supervision and interpretation services, diagnostic radiopharmaceuticals, contrast agents, and observation services. (See Table 10 in Section II.A.4 of the final rule for a comprehensive list of all codes affected by this new policy.) Beginning January 1, 2008, no separate payment will be made for these services, which will be bundled into the services with which they are furnished. However, there will be some instances in which the new “Q” status indicator (SI) will, in fact, be paid if there are no other payable services on the outpatient claim.
The 2008 final OPPS rule can be found at http://www.access.gpo.gov/su_docs/fedreg/a071127c.html. Scroll down to Centers for Medicare & Medicaid Services, Rules, Medicare.
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November 26, 2007
Question:
In last week’s Q&A, you provided information about coverage for
the monitoring of cardiac output (esophageal Doppler) for ventilated patients
in the ICU and operative patients with a need for intra-operative fluid
optimization. What code would be used to report this service when performed
in a hospital for Medicare patients?
Answer:
There is no specific CPT code for this service. CPT code 76999 is for unlisted ultrasound procedures.
When performed in a hospital setting for ventilated patients in the ICU or for operative patients with a need for ultrasound diagnostic procedures, the professional services only are separately payable when billed using CPT code 76999 with the modifier -26 to show professional component.
Such services, when globally billed in a hospital setting with code 76999, will be returned as unprocessable to the provider with a reason code such as 58 denoting “Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.”
When such services are billed in a hospital setting as technical services with the code 76999-TC, Medicare will deny the services with the 58 reason code and an M77 remark code to show “Missing/Incomplete/Invalid place of service.”
The above information and more can be found in Transmittal 76 at http://www.cms.hhs.gov/transmittals/downloads/R76NCD.pdf and MM5608 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5608.pdf.
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November 19, 2007
Question:
What new coverage policy for ultrasound were you talking about last week?
Answer:
On May 22, the Centers for Medicare & Medicaid Services (CMS) announced
a decision to provide coverage for Doppler monitoring of cardiac output
in certain settings. In announcing the decision, CMS stated that it has
determined that
the current evidence supports its decision to revise its longstanding national
coverage determination (NCD) for ultrasound diagnostic procedures and remove
the past noncoverage in these settings. The following will be added to the
list of covered
uses: Monitoring of cardiac output (esophageal Doppler) for ventilated patients
in the ICU and operative patients with a need for intra-operative fluid
optimization. More details can be found at https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=196.
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November 12, 2007
Question:
Where can I find billing guidelines for the new coverage policy related
to ultrasound procedures?
Answer:
On September 6, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 76 (CR 5608) in which it provides billing guidelines as well as revisions to Section 220.5 of the Medicare NCD Manual, Chapter 1, Part 4, which addresses ultrasound diagnostic procedures. The policy described applies to claims with dates of service on and after May 22, 2007.
For comprehensive information, go to Transmittal 76 at http://www.cms.hhs.gov/transmittals/downloads/R76NCD.pdf and MM5608 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5608.pdf.
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November 5, 2007
Question:
Last week you said that Medicare now pays for contrast used for MRI procedures.
Can you provide some billing tips related to this new coverage?
Answer:
Assign the CPT code representing the imaging procedure, and separately bill the appropriate HCPCS "Q" code (Q9945-Q9954; Q9958-Q9964) for the contrast. Comprehensive billing guidelines can be found in MM5677 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5677.pdf and Transmittal 1339 (CR 5677, September 31) at http://www.cms.hhs.gov/transmittals/downloads/R1339CP.pdf.
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October 29, 2007
Question:
Does Medicare pay separately for contrast media used for MRI procedures?
Answer:
On October 22, 2007, the Centers for Medicare & Medicaid Services (CMS)
implemented a new payment policy related to magnetic resonance imaging (MRI)
with an effective date of January 1, 2007. Separate payment will be made
for contrast used.
This payment applies to independent diagnostic testing facilities and other
providers submitting claims to Medicare carriers, fiscal intermediaries
(FIs) and Part A/B Medicare administrative contractors (A/B MACs). For more,
go to transmittal 1339 (CR 5677, September 31) at http://www.cms.hhs.gov/transmittals/downloads/R1339CP.pdf.
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October 22, 2007
Question:
One of our radiologists does not dictate the quantity or type of injected
contrast in his reports. This information can be found elsewhere (tech notes,
etc). I have tried to convince him that this information should be in the
report, and we should not rely on the other documents, but I am afraid my
comments are falling on deaf ears. Should the contrast type and quantity
be contained within the report itself? If yes, is there something in writing
that would lend some to my argument?
Answer:
American College of Radiology (ACR) guidelines state the following: "The report should include a description of the studies and/or procedures performed and any contrast media (including concentration, volume, and route of administration when applicable), medications, catheters, or devices used, if not recorded elsewhere. Any known significant patient reaction or complication should be recorded."
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October 15, 2007
Question:
Can a radiology supplier that renders services to beneficiaries in an
inpatient stay bill the Medicare carrier for the technical component (TC)
of the service?
Answer:
In Transmittal 1221 (April 18, 2007), the Centers for Medicare & Medicaid Services announced that it would establish a common working file (CWF) edit to prevent payments of the technical component (TC) of radiology services furnished to an inpatient by an entity other than the admitting hospital. This policy took effect on April 1, 2007, for claims with dates of service of January 1, 2007, and later.
It now turns out that some imaging services performed on a beneficiary's
admission and discharge dates are being denied based on this edit. In Transmittal
1295 (July 13, 2007), CMS notes that imaging services performed on these
dates by entities other than the admitting hospital are, in fact, separately
payable. Therefore, the edit will now exclude the admission and discharge
dates to permit TC payment.
Note, however, that the general rule has not changed. Specifically, the TC of radiology services provided during an inpatient stay may be billed only by the admitting hospital. Radiology suppliers that render services to beneficiaries in an inpatient stay may not bill the Medicare carrier for the TC except in the above circumstances.
For Transmittal 1221, go to http://www.cms.hhs.gov/transmittals/downloads/R1221CP.pdf. For Transmittal 1295, go to http://www.cms.hhs.gov/transmittals/downloads/R1295CP.pdf.
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October 8, 2007
Question:
Has CMS set a date yet for implementing the new standards for independent
diagnostic testing facilities (IDTFs)?
Answer:
By October 1, 2007, IDTFs must be ready to meet the new supplier standards established by the Centers for Medicare & Medicaid Services. Although these officially took effect on January 1, 2007, CMS has now officially directed Medicare contractors to ensure that IDTFs are in compliance with the 14 performance standards before they bill the Medicare program.
In Transmittal 216, July 13 (http://www.cms.hhs.gov/transmittals/downloads/R216PI.pdf),
CMS updated the sections of the Medicare Program Integrity Manual related
to the performance standards. In this document, you'll find details about
the 14 standards including the following topics:
- When separate enrollment per location is required;
- Multi-state IDTF entities;
- Duties of interpreting and supervising physicians;
- Licensure and certification of technicians; and
- Desk and site reviews.
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October 1, 2007
Question:
Can code 75898 be assigned per vessel or each time a follow up angiogram
is performed post embolization?
Answer:
Currently, the Society of Interventional Radiology (SIR) recommends that, extracranially, this code be used only once per operative field. Intracranially, it may be submitted per injection even if the catheter is not moved to a new vessel location.
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September 24, 2007
Question:
What codes should we use to charge for an ultra-sound guided injection
to sclerosis a lymphocele. This was done through an existing drainage catheter?
Answer:
MedLearn recommends that the following code be used:
76942 Ultrasonic guidance for needle placement (e.g., biopsy, aspiration,
injection, localization device), imaging supervision and interpretation
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September 17, 2007
Question:
In the answer to the September 10 radiology question, you indicated that all positron emission tomography (PET) scans (codes 78459, 78491, 78492, 78608, and 78811-78816) require the use of a radiopharmaceutical (RP) diagnostic imaging agent (tracer).
I am a little confused about this answer. Doesn't this only apply when
billing the technical component (TC)? It would not be billed by the radiology
group performing the professional component only, would it?
Answer:
Only the entity that expends the resources for the material can rightfully bill for it. In other words, if you don't pay for the radiopharmaceutical, you cannot charge for it. You are correct that the guideline given in the question above applies to the TC. Our experience is that (if you paid for the radiopharmaceutical) it is best to start out billing the code for it in addition to the study. Medicare wishes that providers (hospitals and physicians alike) submit both the appropriate A-code as well as the CPT code for the study(s) performed. However, non-Medicare payers have their own sets of rules. Providers must verify exactly what each payer wants regarding claims submission.
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September 10, 2007
Question:
Do all PET scan services require a code for a radiopharmaceutical?
Answer:
Yes, all positron emission tomography (PET) scans (codes 78459, 78491, 78492, 78608, and 78811-78816) require the use of a radiopharmaceutical diagnostic imaging agent (tracer). Therefore, the applicable tracer code should be used when billing for a PET scan service.
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September 3, 2007
Question:
I noticed that CPT code 71275 calls for a without and with contrast run.
Our protocol for a pulmonary embolus is a computed tomography (CT) chest
with contrast only (71260). We also add on 3D rendering (76376). Is this
correct or can we charge for the computed tomography angiography (CTA) since
we do a topogram?
Answer:
As indicated in its descriptor, code 71275 includes image post-processing (the 3-D reconstructions and/or topogram). You must review the documentation carefully to determine whether skeletal anatomy, soft tissues and vessels were imaged and whether a topogram (volumetric data sets) was performed.
If true angiographic (CT) images were done, regardless of whether the without contrast cuts were done, and if the report defines the performance of image post-processing, this is a CTA, and code 71275 would be appropriate. Many departments do not obtain images without contrast, and the presence of the phrase "chest (noncoronary) without contrast material(s)" in the descriptor for code 71275 often causes confusion.
If post processing images (reconstructions) were not performed, the procedure would be billed as a contrast-only chest CT (71260).
If 3D post-processing is done, and the exam is not an angiographic procedure, code 76376 or 76377 (requiring image postprocessing on an independent workstation) could be added to the 71260 (assuming all documentation criteria are met for the 3D option. If 3D is done with the CTA, no additional charge can be submitted for the 3D as this is considered inherent/inclusive in all CTA codes.
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August 27, 2007
Question:
Until last week's Q&A, I hadn't heard about the bundling proposal
for radiology services. Can you provide a few more details about what's
happening?
Answer:
Hospital outpatient services that share clinical and resource characteristics are grouped into ambulatory payment classifications (APCs). A single APC provides one payment for the cost of a primary service and the packaged costs of items directly related to or required to perform that service.
For 2008, the Centers for Medicare & Medicaid Services (CMS) has proposed
extending the APCs to include additional services than they do presently.
Certain services, which CMS has identified as "supportive ancillary
services" are integral to the performance of a primary modality. These
ancillary services would be packaged into the costs of the separately paid
primary
services with which they are usually billed.
In the proposed rule, CMS lists the above in detail and lists all of the codes that would be affected.
For the proposed 2008 OPPS rule, go to http://www.access.gpo.gov/su_docs/fedreg/a070802c.html. Scroll down to Centers for Medicare & Medicaid Services, Proposed Rules, Medicare. The discussion can be found in Section II.A.4-Proposed Changes to Packaged Services.
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August 20, 2007
Question:
Can you tell me where I can find the details about the Medicare proposal
to bundle radiology services by enlarging the APCs?
Answer:
First, the Centers for Medicare & Medicaid Services (CMS) have not proposed to bundle all radiology codes. Of the seven proposed categories slotted for bundling, six do, however, relate to radiology (specifically, guidance services, image-processing, intraoperative services, imaging supervision and interpretation, diagnostic radiopharmaceuticals, and contrast agents). A total of 274 codes are contained in these radiology-specific categories and, of that total, 239 are radiology codes.
The proposed rule for the 2008 OPPS can be found at http://www.
cms.hhs.gov/HospitalOutpatientPPS/HORD/list.
asp#TopOfPage. Scroll down to CMS-1392-P.
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August 13, 2007
Question:
I have been reviewing several central venous line placements. The CPT
definition of 76937 is as follows: ultrasound [US] guidance for vascular
access requiring US evaluation of potential access sites, documentation
of selected vessel patency, concurrent real-time US visualization of vascular
needle entry, with permanent recording and reporting (List separately in
addition to code for primary procedure). As you can see, it includes the
requirement of "documentation of selected vessel patency."
Therefore, I have requested that documentation state something about the
fact that the vessel is patent. However, the radiologists feel that if they
select the vessel under US guidance, it assumes patency.
Am I too particular in requesting the word patency be used?
Answer:
No, you are not too particular. The radiologists need to be informed that they must adhere to CPT guidelines as well as those from the American College or Radiology, Society of Interventional Radiology (SIR), etc.
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August 6, 2007
Question:
I have been told that certain codes for fluoroscopic guidance should not
be reported separately. Can you confirm that this is so?
Answer:
Current correct coding initiative (CCI) edits indicate that codes 76000 or 76001 are components of code 93620 and should not be reported separately. This edit has been in place since October 2003.
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July 30, 2007
Question:
Codes 35495 and 35470 appear to be similar procedures. Can you identify
the differences in their usage?
Answer:
Even though the definition of surgical code 35495 is different from code
35470, they should be used in the same fashion (i.e., per vessel treated).
That's the easy answer to a conundrum that has confused even the best of
coders. In large part, the confusion can be traced back to the fact that
the differences between these two code descriptions (shown below) are subtle
even though they do define the same anatomic areas.
- 35470 Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk
or branches, each vessel
- 35495 Transluminal peripheral atherectomy, percutaneous; tibioperoneal
trunk and branches
Outside the obvious fact that code 35470 describes angioplasty and code 35495 describes atherectomy, code 35470 ends with the phrase "each vessel" and code 35495 includes the phrase "and branches." Based upon the code definition, many coders assume that 35495 should only be used once whether one or all vessels were treated.
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July 23, 2007
Question:
How would the following example be coded?
" Bilateral lower extremity arterial testing was performed demonstrating
asymmetric brachial pressures measuring 143 mm of mercury on the right and
117 mm of mercury on the left. This 26-mm differential may indicate left
subclavian stenosis, but the patient denies any left upper extremity symptoms.
The segmental pressures, as well as the pulse volume records and Doppler
wave forms, are all normal throughout the lower extremities with an ankle
brachial index of 1.17 on the right and 1.12 on the left."
Answer:
The following code would be the appropriate assignment. Two keys can be
found in the above example: No imaging is defined, and there is a reference
to "segmental" pressures.
- 93923 Noninvasive physiological studies of upper or lower extremity arteries,
multiple levels or with provocative functional maneuvers, complete bilateral
study (e.g., segmental blood pressure measurements, segmental Doppler waveform
analysis, segmental volume plethysmography, segmental transcutaneous oxygen
tension measurements, measurements with postural provocative tests, measures
with reactive hyperemia)
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July 16, 2007
Question:
If a patient has bilateral nodules on the thyroid, do we bill 10022 X
2 and 76942 X 2? I'm stuck on how to bill the guidance part since it really
is the same field.
Answer:
If there were right- and left-sided lesions, you would assign the following
code twice:
- 76942 Ultrasonic guidance for needle placement (e.g., biopsy, aspiration,
injection, localization device, imaging)
Also, make sure that you are assigning the correct biopsy code based upon how it was truly done. Options are 10022 for aspirational/FNA studies or 60100 for core needle biopsy.
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July 9, 2007
Question:
I know that Medicare has expanded coverage for Doppler monitoring but
am uncertain of any details. Can you provide?
Answer:
At some point, the following will be added to the list of covered uses: Monitoring of cardiac output (esophageal Doppler) for ventilated patients in the intensive care unit (ICU) and operative patients with a need for intra-operative fluid optimization.
The request to CMS for reconsideration of its longstanding national coverage determination (NCD) came from Deltex Medical Group, manufacturer of the CardioQ esophageal Doppler monitor. The company asserted that the existing NCD pre-dated the commercial availability of both the CardioQ and its predecessor devices; much, if not all, of the validation data; and all of the peer-reviewed, randomized controlled clinical trial data.
For this decision, go to https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=196.
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July 2, 2007
Question:
Have the codes to report bone mass measurement (BMM) changed as a result
of the new coverage addressed in last week's question and answer?
Answer:
As stated in the 2007 CPT manual, several codes formerly used to report
BMM were deleted. In Transmittal 1236, CMS officially announced the new
2007 replacement codes as follows:
- 77078 replaces 76070
- 77079 replaces 76071
- 77080 replaces 76075
- 77081 replaces 76076
- 77083 replaces 76078
For Transmittal 1236, go to http://www.cms.hhs.gov/transmittals/downloads/R1236CP.pdf.
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June 25, 2007
Question:
I understand that Medicare has changed the coverage of bone mass measurement
(BMM). Can you provide resources for this change?
Answer:
On May 11, the Centers for Medicare & Medicaid Services issued the
three transmittals listed below, which relate to BMM. The information contained
in the transmittals has an effective date of January 1, 2007, and will be
implemented on July 2, 2007.
- Transmittal 69-update to the Medicare NCD Manual - at http://www.cms.hhs.gov/transmittals/downloads/R69NCD.pdf
- Transmittal 70-update to the Medicare Benefit Policy Manual - at
http://www.cms.hhs.gov/transmittals/downloads/R70BP.pdf
- Transmittal 1236-update to the Medicare Claims Processing Manual
- at http://www.cms.hhs.gov/transmittals/downloads/R1236CP.pdf
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June 18, 2007
Question:
We are a teaching facility, and we bill the professional side for radiology
performed. We have a compliance auditor who says that when we have a resident
dictating the final report the statement "I personally viewed the images
and approve this report" must be stated. The way it is listed now,
there is a section that says "dictated by" and "electronically
signed by." Is this sufficient, or should the suggested statement be
in place to be compliant? CMS teaching guidelines do not state that this
statement is required.
Answer:
A section of Chapter 12 of the Medicare Claims Processing Manual provides detailed directives for teaching physicians in the radiology setting. Among other things, it says the following:
Medicare pays for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by or reviewed with a teaching physician. If the teaching physician's signature is the only signature on the interpretation, Medicare assumes that he/she is indicating that he/she personally performed the interpretation. If a resident prepares and signs the interpretation, the teaching physician must indicate that he/she has personally reviewed the image and the resident's interpretation and either agrees with it or edits the findings. Medicare does not pay for an interpretation if the teaching physician only countersigns the resident's interpretation.
For this information and more about the interpretation of diagnostic radiology and other diagnostic tests, go to Section 100.1.2 at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.
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June 11, 2007
Question:
I have a report that states the following: "bilateral internal carotid catheterizations with imaging over the head." The interpretation states: "Bifurcation angiogram is normal bilaterally. Internal carotid artery injections revealed a patent distal cervical, petrous, cavernous and supraclinoid portions of the right ICA. There is a right periophthalmic artery aneurysm, measuring 2.6."
Is mention of the distal cervical enough to code 75680 along with 75671?
Answer:
The report definitely includes mention of the cervicals. Based upon the limited info you provide in your question, this meets the definition of the code, and you could bill for it as such.
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June 4, 2007
Question:
My radiologist asked me to see how other practices are handling the actual
processing of 3D images. He does the entire reconstruction process himself,
and we charge for the professional component. We are hospital-based, and
his concern is how and why can the hospital also charge a substantial fee
for this when, in his opinion, it does nothing? Do other practices have
the techs handle the reprocessing, or do the radiologists do it themselves?
Answer:
The hospital incurred the expense of purchasing, maintaining and all other costs required for the day-to-day operations of the device. Hospitals expend a lot of capital for the materials necessary to provide and perform these services. If this equipment was located in a freestanding (or non-hospital) setting, you would bill globally for the same service. In that instance, the radiologists would be paid for the technical portion of the service as well as the read of it. Would the physician want to reduce his fee in that scenario because it was too much? I'm guessing no. This is no different than what the hospital is doing right now.
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May 28, 2007
Question:
We have been advised to use ICD-9-CM code V71.4 (observation following
other accident) on reports documenting a clinical history of "fall"
or "MVA" with negative results. We have been making that leap
from fall to injury and using an injury ICD-
9 code. I feel that our radiologists are not observers.
Answer:
The radiologists should be provided a valid condition or symptom rather than a cause of the condition or symptom. The staff that registers the patient for the test should query the referring provider to obtain this information in most cases. The staff can also query the patient to obtain (i.e., "fall" might have resulted in hip pain).
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May 21, 2007
Question:
I have a follow-up question to the 4-30-07 radiology Q&A, which is provided below for reference:
Q. I have a report for both an aspiration biopsy and core biopsy of the L3-4 disc under fluoroscopy. The following codes were assigned: 62287, 10022 and 76005. Is 62287 the appropriate code for core biopsy of the disc, or should we still be using an unlisted procedure code (UPC) for this portion of the procedure?
A. We would suggest that you not use the code 62287 for what you describe.
Also, remember for 2007 that you will want to assign 77003 instead of 76005
for pain management-type procedures. Based upon your info, you should consider
assigning 76003 (for 2006 claims) or 77002 (for 2007) claims.
My question is if code 62287 should not be used, what code do you recommend
for core biopsy of the L3-4 disc?
Answer:
While most will assess only the single code 10022, if these were indeed two separate procedures, the core disc biopsy would be defined by an unlisted procedure code.
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May 14, 2007
Question:
Are we still suppose to use the supervision and interpretation code 75978
with the new HCPS code G0393 (PTA hemodialysis access, venous)?
Answer:
Yes. Per CMS, the new A-V PTA codes are supposed to be reported for PTA within the graft/fistula in the same manner as the traditional CPT codes for PTA have been with catheterization, imaging and concomitant services separately reportable.
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May 7, 2007
Question:
Can you tell me whether bill type 12X is appropriate for diagnostic mammograms?
Answer:
Back in the June 2006 issue, the Centers for Medicare & Medicaid Services (CMS) removed type of bill (TOB) 12X from the list of applicable TOBs for diagnostic mammography. However, in Transmittal 1117 (Change Request 5377, November 26, 2006), CMS announced that it had "erroneously removed" TOB 12X from the list of applicable TOBs.
Effective April 1, 2007, hospitals that bill fiscal intermediaries (FIs) or Part A/B Medicare administrative contractors (A/B MACs) for diagnostic mammograms provided to hospital inpatients may use TOB 12X when the services are being billed to Medicare Part B. As appropriate, hospitals should continue to use TOBs 13X, 22X, 23X, or 85X when billing for diagnostic mammographies provided to Medicare patients who are other than hospital inpatients.
For the above transmittal, go to http:// www.cms.hhs.gov/transmittals/downloads/R1117CP.pdf.
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April 30, 2007
Question:
I have a report for both an aspiration biopsy and core biopsy of the L3-4
disc under fluoroscopy. The following codes were assigned: 62287, 10022
and 76005. Is 62287 the appropriate code for core biopsy of the disc, or
should we still be using an unlisted procedure code (UPC) for this portion
of the procedure?
Answer:
We would suggest that you not use the code 62287 for what you describe. Also, remember for 2007 that you will want to assign 77003 instead of 76005 for pain management-type procedures. Based upon your info, you should consider assigning 76003 (for 2006 claims) or 77002 (for 2007) claims.
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April 23, 2007
Question:
I need a crash course on independent diagnostic testing facilities (IDTFs).
We have an imaging center that is designated as an IDTF, but I think it
qualifies as a physician's office (ownership is 50% hospital / 50% radiology
group). Any direction on where I should begin my education would be appreciated.
Answer:
Guidelines related to IDTFs can be found in the Medicare Program Integrity Manual, Chapter 10, Section 4.19 at http://www.cms.hhs.gov/manuals/downloads/pim83c10.pdf.
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April 16, 2007
Question:
Can you provide any advice on the codes to assign for the following?
- DOS 01/30/07 Zevalin whole body scan
- DOS 02/06/07 Zevalin therapy for treatment of lymphoma
Answer:
For whole body imaging, assign one of the following codes, depending on
the number of days the patient was imaged.
- 78802 Radiopharmaceutical localization of tumor or distribution of RP
agent(s); whole body, single day imaging
- 78804 whole body, requiring two or more days imaging
Assign code 79403 for radiopharmaceutical therapy, radio-labeled monoclonal antibody by intravenous infusion.
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April 9, 2007
Question:
Has Congress made any progress on reversing or reducing the imaging cuts
mandated by the Deficit Reduction Act (DRA) of 2005?
Answer:
On March 1, 2007, several members of Congress introduced The Access to
Medicare Imaging Act of 2007 (HR 1293) to address the Medicare payment cuts.
On that day, it already had 42 cosponsors and now has 59. HR 1293 includes
several recommendations, including the following.
- A two-year moratorium on "certain" Medicare physician payment
reductions for "advanced" diagnostic imaging services (magnetic
resonance imaging, computed tomography, positron emission tomography, and
nuclear cardiology procedures.
- A comprehensive study conducted by the U.S. General Accountability Act
(GAO) on patient access and service issues relating to the availability
and quality of advanced diagnostic imaging services in physician offices
and freestanding clinics
- Examine the appropriateness of using the hospital outpatient prospective
payment system (OPPS) methodology to set reimbursement under Medicare for
all advanced diagnostic imaging services, regardless of site of service.
For more on this legislation, go to http://thomas.loc.gov/ and search by the bill number.
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April 2, 2007
Question:
Where on the CMS-1500 should the referring physician's name be placed?
Answer:
The Centers for Medicare & Medicaid Services (CMS) recently issued an article listing the most frequent errors found in claims submitted to Medicare carriers. It provided the answer to your question as follows. The referring or ordering physician's name and identification number must be included in item 17 and 17a for all diagnostic services, including consultations.
Information about the most common Medicare billing errors, including the above, is taken from SE0712, which can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0712.pdf.
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March 26, 2007
Question:
Will Medicare carriers reimburse the technical component of radiology services
when furnished at skilled nursing facilities?
Answer:
No, carriers may not pay for the TC of radiology services furnished to SNF inpatients during a Part A covered stay. The SNF must bill fiscal intermediaries (FIs) for the inpatient services, and payment is included in the SNF prospective payment system (PPS).
Radiology services furnished to SNF outpatients may be billed by the supplier performing the service or by the SNF under arrangements with the supplier. If billed by the SNF, FIs pay according to the Medicare physician fee schedule. SNFs submit claims to the FI with type of bill 22X or 23X.
Information about this can be found in the Medicare Claims Processing Manual, Chapter 13, Section 20.2.1. CMS recently revised this section in Transmittal 1098, which can be found at http://www.cms.hhs.gov/transmittals/downloads/R1098CP.pdf.
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March 19, 2007
Question:
Can a radiologist bill Medicare for the technical component of a radiology
service furnished to an inpatient?
Answer:
The Centers for Medicare & Medicaid Services (CMS) recently announced its intent to install a common working file (CWF) edit to prevent Medicare carriers from paying for the technical component (TC) of a radiology service provided during an inpatient stay. When a non-hospital entity (i.e., physician or supplier) furnishes the TC of a radiology service to a hospital inpatient, the TC is excluded from coverage unless it is performed under an arrangement whereby the hospital must bill the intermediary.
In Transmittal 1098, CMS explained that noncompliance by Medicare carriers is the reason for the edit. Apparently the Department of Health & Human Services Office of Inspector General discovered that carriers were paying twice-once to the hospital that billed the intermediary and again to the radiology supplier or physician that billed the carrier.
Go to http://www.cms.hhs.gov/transmittals/downloads/R1098CP.pdf for the transmittal.
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March 12, 2007
Question:
If a physical exam is performed in conjunction with a diagnostic mammogram
or breast ultrasound and the results are discussed with the patient, is
it appropriate to bill for an office visit, 99212, if performed in a private
office setting?
Answer:
It is only appropriate to bill for a consultation or other evaluation and management (E&M) service when it is provided and documented according to established E&M guidelines. For breast interventional procedures, a brief review of history and physical exam and obtaining informed consent is not a separately reportable E&M service. This service is considered bundled into the surgical procedure code.
The E&M documentation guidelines are being revised. Until they are finalized, it is up to the provider to use either the 1995 or 1997 published guidelines. It is recommended, however, that for auditing purposes a radiology practice use one set of guidelines (that is, either the 1995 guidelines or the 1997 guidelines).
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March 5, 2007
Question:
What radiology codes fall into the new "special packaged" status?
Answer:
Only one radiology code falls into the special packaged category and that is 75893--venous sampling through catheter, with or without angiography, radiological supervision and interpretation. In 2007, Medicare will pay separately for special packaged codes when they appear on a claim with no separately payable OPPS services also reported for the same date of service (DOS). In Addendum B of the 2007 final OPPS rule, this code is listed with a payment rate of $383.95.
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February 26, 2007
Question:
What type of bill must be assigned for screening mammograms?
Answer:
Up until July 1, 2006, type of bill (TOB) 13X (hospital, outpatient, Part B) was used. For claims with dates of service on and after July 1, 2006, assign TOB 12X for screening mammograms provided to hospital inpatients under Part B. In Transmittal 827 (February 1, 2006), CMS stated that all other TOBs (13X, 22X, 23X, and 85X) for services other than hospital inpatients remain the same for screening mammography. Also in this transmittal you will find other billing guidelines from Chapter 18 of the Medicare Claims Processing Manual for screening (as well as diagnostic) mammograms. Go to http://www.cms.hhs.gov/transmittals/downloads/R827CP.pdf for the transmittal.
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February 19, 2007
Question:
Where can I find information about the new coverage of bone mass measurement
tests?
Answer:
These changes were made in the 2007 Medicare physician fee schedule (MPFS)
and instructions appeared in Transmittal 258, which CMS issued on December
22, 2006. This transmittal can be found at http://www.cms.hhs.gov/transmittals/downloads/R258OTN.pdf.
Related provider-information memo MM5443 can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5443.pdf.
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February 12, 2007
Question:
What type of mammogram should a patient receive who has a personal history
of biopsy-proven benign breast disease?
Answer:
According to the ACR Standard for Diagnostic Mammography, a diagnostic
mammogram is appropriate. Also, in the December 8, 1995, Federal Register,
CMS expanded its definition of diagnostic mammography to include a personal
history of biopsy-proven benign breast disease, thereby allowing the attending
physician and the patient the opportunity to determine whether a screening
or a diagnostic mammogram is performed.
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February 5, 2007
Question:
I need help assigning codes to the following report. Should it be coded
as 78445, 36598 or both?
INDICATION: Pt referred for evaluation of patency of right chest port.
METHOD: After injection of 5 millicuries of TC-99M MAG-3 through the right
port-a-cath sequential images and static blood pole images of the chest
were obtained. FINDINGS: After port injection the flow of radioactivity
follows the port course with no signs of obstruction or hold-up. Once the
radioactivity is within the circulation there is normal physiologic distribution.
The delayed images show evidence of blood pole redistribution of radioactivity.
IMPRESSION: Right chest port patent as described above.
Answer:
Since the main intent appears to be to verify patency, assign only 784454
for the flow study. If this study was only to follow the distribution (report
should say blood pool as opposed to blood pole) of the isotope (which is
appears to not be the primary focus of this exam), code 78800 would fit
the bill.
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January 29 , 2007
Question:
Our radiologists are wondering if there is an extra charge for placement
of an IV that is much bigger than the typical IV and more complex, done
under ultrasound guidance. They would like to assign code 36000 with 76937.
Does that sound ok?
Answer:
MedLearn's radiology consultants see the following problems with this scenario:
- Every person that gets an IV contrast CT or CTA study has to get an injection.
This says that the insertion of the needle/intracath, etc is an integral
component of the study. It is not by definition a "separate procedure."
- CCI edits show that the reporting of any of the codes for injection or
device placement is considered to be part of the enhanced CT/CTA exam.
- This is your site-specific routine, so the ultimate size/bore of the needle/intracath
does not create an exception to what CCI or CPT states.
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January 22, 2007
Question:
We have never charged GAD in addition to an MRI. If charged, will this be
paid?
Answer:
Yes, gadolinium will be paid separately in 2007. Use codes Q9952-Q9954 to
report its use in all settings. This is a new payment policy so the Medicare
manuals still (as of this writing) contain the old nonpayment verbiage.
The Centers for Medicare & Medicaid Services has indicated that it will
issue a change request related to this payment policy.
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January 15, 2007
Question:
I heard Medicare has changed its payment policy for brachytherapy. Can you
describe the changes?
Answer:
From January 1, 2004, through December 31, 2006, payment for brachytherapy
was on a per-source basis at an amount equal to the hospital’s charge
adjusted to cost by application of the hospital-specific overall cost-to-charge
ratio (CCR). For 2007, payment for brachytherapy sources will be made at
a prospectively determined rate for each source for which there is claims’
data, and each source is assigned to its own ambulatory payment classification
(APC).
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January 8, 2007
Question:
What is the status of the plan to reduce the hospital payments for multiple
imaging procedure payment reduction?
Answer:
In the 2006 final rule, the Centers for Medicare & Medicaid Services
(CMS) proposed to reduce 2007 hospital outpatient prospective payment system
(OPPS) rates for some second and subsequent diagnostic imaging procedures
performed during the same session. Over the past seven months, it conducted
additional studies of hospital claims data for single and multiple diagnostic
imaging procedures. The results of those analyses support its final decision
to defer implementation of a multiple imaging procedure payment reduction
policy in the OPPS in 2007.
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January 1, 2007
Question:
Is it appropriate to use code 78320 with codes 78300 or 78305 but not with
78306 (bone/joint whole body)?
Answer:
No, this is not appropriate. The exact opposite is, in fact, true. You cannot
use code 78320 (bone and/or joint imaging; tomographic (SPECT) with code
78300 (bone and/or joint imaging; limited area) or 78305 (bone and/or joint
imaging; multiple areas).
However, you may use 78320 with code 78306 (bone and/or joint imaging; whole body).