Dial-In Instructions Conference Name:

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

Scheduled Conference Date:

Tuesday, April 25th, 2006

Scheduled Conference Time:

1:00 p.m.–2:30 p.m. (Eastern), 12:00 p.m.–1:30 p.m. (Central), 11:00 a.m.– 12:30 p.m. (Mountain), 10:00 a.m.–11:30 a.m (Pacific)

Scheduled Conference Duration:

90 Minutes

PLEASE NOTE: If the audioconference occurs April through October, the time reflects daylight savings. If your area does NOT observe daylight savings, times will be one hour earlier. Your registration entitles you to ONE telephone connection to the audioconference. Invite as many people as you wish to listen to the audioconference on your speakerphone. Permission is given to make copies of the written materials for anyone else who is listening. In order to avoid delays in connecting to the conference, we recommend that you dial into the audioconference 15 minutes prior to the start time.

Dial-In Instructions: 1. Dial 877/407-6050 and follow the voice prompts. 2. You will be greeted by an operator 3. Give the operator your pass code 605240 and the last name of the person who registered for the audioconference. 4. The operator will verify the name of your facility. 5. You will then be placed into the conference. Technical Difficulties 1. If you experience any difficulties with the dial-in process, please call the conference center reservation line at 877/407-7177. 2. If you should need technical assistance during the audio portion of the program, please press the star (*) key followed by the 0 key on your touch-tone phone and an operator will assist you. If you are disconnected during the conference, dial 877/407-2989. Q&A Session 1. To enter the questioning queue during the Q&A session, callers need to push the star (*) key followed by the 1 key on their touch-tone phones. Note: For most programs, this portion of the program generally falls after the first hour of presentation. Please do not try to enter the queue before this portion of the program. 2. If you prefer not to ask your question on the air, you can fax your question to 877/808-1533 or 201/612-8027. However, note that you can only fax your question during the program. Prior to the Program If you prefer not to ask your question on the air, you can send your questions via email to [email protected]. The deadline for questions is 04/24/06 @ 5:30 PM Eastern. Please note that it is likely that not all questions will be answered. Program Evaluation Survey In your materials on page 2, we have included a Program evaluation letter that has the URL link to our program survey. We would appreciate it if when you return to your office you would go to the link provided and complete the survey. Continuing Education Documentation If CE’s are offered with this program, a separate link containing important information will be provided along with the program materials. Please follow the instructions in the CE Documentation.

Program Evaluation Dear Audioconference Participant, Thank you for attending the HCPro program today. We hope that you find the information provided valuable. In our effort to ensure that our customers have a positive experience when taking part in our programs we are requesting your feedback. We would also like to request that you forward the link to others in your facility who attended the program. We realize that your time is valuable, so we’ve limited the evaluation to a few brief questions. Please click on the link below. http://www.zoomerang.com/survey.zgi?p=WEB22562YAT93H The information provided from the evaluation is crucial towards our goal of delivering the best possible products and services. To insure that your completed form receives our attention, please return to us within six days from the date of this program. We appreciate your time and suggestions. We hope that you will continue to rely on HCPro programs as an important resource for pertinent and timely information.

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200 Hoods Lane PO Box 1168 Marblehead MA 01945

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781 639 1872

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www.hcpro.com

presents . . .

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement A 90-minute interactive audioconference Tuesday, April 25, 2006 1:00 p.m.–2:30 p.m. (Eastern) 12:00 p.m.–1:30 p.m. (Central) 11:00 a.m.–12:30 p.m. (Mountain) 10:00 a.m.–11:30 a.m. (Pacific)

In our materials, we strive to provide our audience with useful, timely information. The live audioconference will follow the enclosed agenda. Occasionally our speakers will refer to the materials enclosed. We have noticed that other non-HCPro audioconference materials follow the speaker’s presentation bullet-by-bullet, page-by-page. Because our presentations are less rigid and rely more on speaker interaction, we do not include each speaker’s entire presentation. The materials contain helpful forms, crosswalks, policies, charts, and graphs. We hope that you find this information useful in the future. HCPro is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations, which owns the JCAHO trademark.

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

The “Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement” audioconference materials package is published by HCPro, 200 Hoods Lane, P.O. Box 1168, Marblehead, MA 01945. Copyright 2006, HCPro, Inc. Attendance at the audioconference is restricted to employees, consultants, and members of the medical staff of the Licensee. The audioconference materials are intended solely for use in conjunction with the associated HCPro audioconference. Licensee may make copies of these materials for your internal use by attendees of the audioconference only. All such copies must bear this legend. Dissemination of any information in these materials or the audioconference to any party other than the Licensee or its employees is strictly prohibited. Advice given is general, and attendees and readers of the materials should consult professional counsel for specific legal, ethical, or clinical questions. HCPro is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations, which owns the JCAHO trademark. For more information, contact HCPro, Inc. 200 Hoods Lane P.O. Box 1168 Marblehead, MA 01945 Phone: 800/650-6787 Fax: 781/639-0179 E-mail: [email protected] Web site: www.hcpro.com

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

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200 Hoods Lane P.O. Box 1168 Marblehead, MA 01945 Tel: 800/650-6787 Fax: 800/639-8511

Dear colleague,

Thank you for participating in our “Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement” audioconference with Stacie L. Buck, RHIA, LHRM, and Stacy M. Gregory, RCC, CPC, moderated by Melissa Varnavas. We are excited about the opportunity to interact with you directly and encourage you to take advantage of the opportunity to ask our experts your questions during the audioconference. If you would like to submit a question before the audioconference, please send it to [email protected] and provide the program date in the subject line. We cannot guarantee that your question will be answered during the program, but we will do our best to take a good cross-section of questions. If at any time you have comments, suggestions, or ideas about how we might improve our audioconferences, or if you have any questions about the audioconference itself, please do not hesitate to contact me. And if you would like any additional information about other products and services, please contact our Customer Service Department at 800/650-6787. Along with these audioconference materials, we have enclosed a fax evaluation. We value your opinion. After the audioconference, please take a minute to complete the evaluation to let us know what you think. Thanks again for working with us. Best regards,

Abigail Gresla Associate producer Fax: 781/639-2982 E-mail: [email protected]

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

Contents Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi Speaker profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii Exhibit A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Presentation by Stacie L. Buck, RHIA, LHRM, and Stacy M. Gregory, RCC, CPC

Exhibit B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 Medicare’s Requirements for Ordering Diagnostic Tests

Exhibit C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 Incomplete Test Orders Tracking Sheet

Exhibit D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 ICD-9-CM Coding Requirements for Diagnostic Tests

Exhibit E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 Ordering Mammograms: Screening vs. Diagnostic

Exhibit F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 Modifier -59 Decision Tree

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

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Agenda I. II. III. IV. V. VI. VII.

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Overview of radiology documentation challenges Diagnostic test order guidelines Radiology report documentation guidelines CPT coding and documentation duidelines ICD-9 coding guidelines for diagnostic test Medical necessity for diagnostic tests Live Q&A

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

Speaker profiles Stacie L. Buck, RHIA, LHRM Stacie L. Buck, RHIA, LHRM, is vice president of Southeast Radiology Management in Stuart, FL. Stacie has served in several different roles during her 14-year career in health information management including as a medical records coordinator, medical coder, a revenue analyst, an internal auditor, corporate compliance officer, and consultant. Stacie is on the editorial advisory board for the HCPro newsletters Mammography Regulation Report, Radiology Administrator's Compliance Insider, Health Care Auditing Strategies and she is a frequent contributor to Strategies for Health Care Compliance and to Compliance Monitor Q & A's Ask the Expert. In addition, she is the author of the recently released Radiology Technologist's Coding Compliance Handbook, Medical Necessity Training Handbook for Physicians, Medical Necessity Training Handbook for Nurses and Hospital Staff and the ABN Training Handbook for Physician Practices. This year Stacie was the recipient of several awards including the 2005 AHIMA Rising Star Award, FHIMA Outstanding Professional Award & FHIMA Literary Award. She currently serves on the FHIMA Board of Directors and is President-Elect for the Suncoast Health Information Management Association.

Stacy M. Gregory, RCC, CPC Stacy M. Gregory, RCC, CPC, is currently employed as a charge capture and reconciliation specialist at Franciscan Health Systems in Tacoma, WA. Gregory is an accomplished radiology coder, consultant and charge capture specialist with a sincere passion for coding and compliance. In her seven years of experience with radiology coding and billing, Gregory has served as a billing manager, medical coder, coding manager, educator, revenue support specialist, and consultant. She has been an active member of various radiology coding discussion groups and has been featured in several well-recognized coding publications, including The Coding Institute’s Radiology Coding Alert. Gregory is the sole proprietor and senior consultant for Gregory Medical Consulting Services, also based in Tacoma. She is a member of numerous professional organizations and actively participates in continuing education opportunities for all areas of her field.

Melissa Varnavas (moderator) Melissa Varnavas is a managing editor for the compliance market at HCPro, Inc. She edits Radiology Administrators’ Compliance & Reimbursement Insider as well as the e-zines Imaging Weekly and Stem Cell Regulation Report.

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Exhibit A Presentation by Stacie L. Buck, RHIA, LHRM, and Stacy M. Gregory, RCC, CPC

EXHIBIT A

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement Presented by: Stacie L. Buck, RHIA, LHRM Stacy Gregory, CPC, RCC 1

Overview of Radiology Coding Challenges • Documentation Making sure physicians, technologists and coders understand & adhere to the CPT, CMS and ACR documentation requirements

• Medical Necessity What is the reason the exam is being performed? Was it ordered by a physician? Does it really need to be done?

• Integration/Collaboration Developing a partnership between coding staff and physicians for overall organizational success 2

2

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

Overview of Radiology Documentation Challenges • • • •

Doppler vs. Duplex CT vs. CTA 3D Reformatting/Reconstructions Contrast materials Oral or IV? What type/strength? How much?

• Permanent Images What constitutes a “permanent image”? How long must the image be stored? Does this need to be documented in the radiology report?

• Supervision and Interpretation (S&I) • PET and PET/CT 3

Overview of Radiology Documentation Challenges • The “Golden Rule”:

“If it isn’t documented, it didn’t happen!”

4

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

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EXHIBIT A

Whistleblower Case • June 23, 2004 – DOJ announced that Radiology Regional Center, PA, (FL) had agreed to pay $2.5 million to settle charges that it filed false Medicare claims. • The suit alleged that the group billed for numerous studies that treating physicians did not order or otherwise were not reimbursable. – Retroperitoneal ultrasound procedures (76770) – Noninvasive physiologic studies of the extracranial arteries and extremity veins performed in conjunction with duplex scans of the same arteries and veins (93875/93880, 93965/93970, 93965/93971) – magnetic resonance imaging (MRI) of the orbit, face and neck – reconstruction imaging (76375) – Mammograms that the DOJ alleged did not qualify as diagnostic and should have been billed as screening mammograms Source: ACR Coding Source, July/Aug 2004

5

Lessons from the Florida Case • Ordering of Diagnostic Tests - practices must know what rules apply to each place of service (ie, hospital vs. freestanding vs. office setting). • Reinforces the need for radiologists to communicate with referring physicians and to document their efforts to obtain adequate orders and clinical indications when necessary for a requested study—even if the referring physician or office fails to provide such vital information • Shows the value of a useful compliance plan that follows the OIG model guidance for physician practices Source: ACR Coding Source, July/Aug 2004

4

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

Why the confusion? • Different rules for different settings – Hospital – Provider Based – IDTF

7

Diagnostic Test Orders Guidelines

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

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EXHIBIT A

42 CFR 482.26 • Radiology services must be provided only on the order of practitioners with clinical privileges, or consistent with state law, or other practitioners authorized by the medical staff and governing body to order the services.

9

42 CFR 410.32 • All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. • Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary 10

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

42 CFR 410.32 • Mammography exception. A physician who meets the qualification requirements for an interpreting physician may order a diagnostic mammogram based on the findings of a screening mammogram even though the physician does not treat the beneficiary.

11

42 CFR 410.33 - IDTFs • All procedures performed by the IDTF must be specifically ordered in writing by the physician who is treating the beneficiary • The supervising physician for the IDTF may not order tests to be performed by the IDTF, unless the IDTF’s supervising physician is in fact the beneficiary’s treating physician. • IDTF may not add any procedures based on internal protocols without a written order from the treating physician.

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

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EXHIBIT A

Common Questions • Does the referring physician need to include signs/symptoms or a diagnosis? • What constitutes an order? • Can a testing facility modify an order? • Can a testing facility perform additional tests if necessary? • Are there any exceptions to the rules? 13

Does the referring physician need to include signs/symptoms or a diagnosis? • Section 4317(b) of the Balanced Budget Act (BBA), requires referring physicians to provide this diagnostic information to the testing entity at the time the test is ordered. If the referring physician indicates a “rule out”, he/she must also include signs/symptoms prompting the exam for the “rule out” condition.

14

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

What constitutes an order? • An "order" is a communication from the treating (referring) physician/practitioner requesting that a diagnostic test be performed for a beneficiary. – Written document – Telephone call – Email

• May be conditional 15

Can a testing facility modify a test order or perform additional tests? • The treating (referring) physician/practitioner must order all diagnostic tests furnished to a beneficiary who is not an institutional inpatient or outpatient. • A testing facility that furnishes a diagnostic test ordered by the treating physician/practitioner may not change the diagnostic test or perform an additional diagnostic test without a new order. • This policy is intended to prevent the practice of some testing facilities to routinely apply protocols which require performance of sequential tests. 16

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

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EXHIBIT A

Can a testing facility modify a test order or perform additional tests? • Depending upon the site of service (hospital vs. nonhospital), additional nonordered imaging cannot be performed unless it falls into very specific and explicit safe harbors. – Medicare's Ordering of Diagnostic Tests rule (Medicare Carriers Manual 15021, Transmittal 1725) – The performance and coding of an additional limited diagnostic ultrasound study clearly does not meet those criteria in a nonhospital setting. In a hospital setting, the answer is less clear, but a conservative interpretation would indicate that this is problematic as well. Source: ACR Coding Source, Sept/Oct 2005

17

Are there any exceptions to the rules? • YES! – 5 criteria for additional tests must be met • • • •

Test originally ordered is performed Based on result additional diagnostic test is necessary Delaying performance of test would have adverse effect Result communicated to referring physician and used in treatment of patient • Interpreting physician documents why additional testing is done

– Test design – Clear error – Patient condition 18

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

Radiology Report Documentation Guidelines

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ACR Practice Guidelines for Communication • “Effective communication is a critical component of diagnostic imaging. Quality patient care can only be achieved when study results are conveyed in a timely fashion to those ultimately responsible for treatment decisions.” • “An official interpretation (final report) shall be generated and archived following any examination, procedure, or officially requested consultation regardless of the site of performance (hospital, imaging center, physician office, mobile unit, etc.)”

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

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EXHIBIT A

ACR Practice Guidelines for Communication • Demographics

• Findings

• Clinical indications

• Limitations

• Description of procedures

• Clinical issues

• Materials

• Impression

• Comparative Data

http://www.acr.org/s_acr/bin.asp?TrackID=&SID=1&DID=12196&CID=541&VID=2&DOC= http://www.acr.org/s_acr/bin.asp?CID=539&DID=12267&DOC=FILE.PDF 21

CPT Coding & Documentation Guidelines

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

Documentation Guidelines • CPT-Specific Guidelines – Carefully review the guidelines at the beginning of each section in CPT. – Know and adhere to the subsection- and codespecific guidelines & documentation requirements. – Utilize CPT Assistant references when available/applicable.

23

US Documentation Guidelines CPT • Permanently recorded images with measurements, when such measurements are clinically indicated. • A final, written report • Complete vs. limited • To code complete – a description of elements or the reason an element could not be visualized (eg, obscured by bowel gas, surgically absent etc.). • If less than the required elements for a "complete" exam are reported (eg, limited number of organs or limited portion of region evaluated), the "limited" code for that anatomic region should be used once per patient exam session. 24

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

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EXHIBIT A

US Documentation Guidelines • Doppler evaluation of vascular structures is separately reportable (other than color flow used only for anatomic structure identification). 93875-93990 • Ultrasound guidance – permanently recorded images of the site to be localized – documented description of the localization process, either separately or within the report of the procedure for which the guidance is utilized.

• Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable.

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US Documentation Guidelines (cont.) • For those anatomic regions that have "complete" and "limited" ultrasound codes, note the elements that comprise a "complete" exam. The report should contain a description of these elements or the reason that an element could not be visualized (eg, obscured by bowel gas, surgically absent etc.). • If less than the required elements for a "complete" exam are reported (eg, limited number of organs or limited portion of region evaluated), the "limited" code for that anatomic region should be used once per patient exam session. A "limited" exam of an anatomic region should not be reported for the same exam session as a "complete" exam of that same region. 26

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

Abdomen - Complete • • • • • • • •

Liver Gall bladder Common bile duct Pancreas Spleen Kidneys Upper abdominal aorta Inferior vena cava 27

Limited US - Abdomen • If an US is performed on 2 quadrants (LLQ & RLQ) is it appropriate to bill 76705 twice?

Source: CPT Assistant, April 2003

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

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EXHIBIT A

Retroperitoneum - Complete • • • • •

Kidneys Abdominal aorta Common iliac artery origins Inferior vena cava, If clinical history suggests urinary tract pathology include – Kidneys – Urinary bladder 29

Limited Retroperitoneum • What code should be reported for US of the bladder alone? – Kidneys alone?

Source: CPT Assistant, May 1999

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

OB – 76801, 76802 First Trimester

• Determination of # of gestational sacs and fetuses • Gestational sac/fetal measurements appropriate for gestation ( or = 14 weeks 0 days) – Biparietal diameter head circumference – Femur length – Abdominal circumference

• • • • • •

Survey of intracranial/spinal/abdominal anatomy 4 chambered heart Umbilical cord insertion site Placenta location Amniotic fluid assessment Examination of maternal adnexa (when visible) Source: CPT Assistant March 2003

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

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EXHIBIT A

Obstetrical 76811, 76812 • Performed for pregnancies at elevated risk of birth defects • All elements of 76085 & 76810 plus: • Detailed anatomic evaluation of: – – – – – – – –

the fetal brain/ventricles face heart/outflow tracts and chest anatomy abdominal organ specific anatomy number/length/architecture of limbs umbilical cord placenta other fetal anatomy as clinically indicated Source: CPT Assistant March 2003

33

OB - 76815 • Use 76815 for a quick look of one or more of elements in code • Code 76815 per exam, not fetus

Source: CPT Assistant March 2003 34

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

OB -76816 • Reassessment of fetal size and interval growth • Re-evaluate anatomic abnormalities on a previous US • Code once per fetus • Append modifier -59 for each additional fetus Source: CPT Assistant March 2003 35

Transabdominal US - 76856 • Includes the complete evaluation of the female pelvic anatomy. – description and measurements of the uterus and adnexal structures, – measurement of the endometrium, – measurement of the bladder (when applicable), – a description of any pelvic pathology (eg, ovarian cysts, uterine leiomyomata, free pelvic fluid). • Applicable to a complete evaluation of the male pelvis. – evaluation and measurement (when applicable) of the urinary bladder – evaluation of the prostate and seminal vesicles to the extent that they are visualized transabdominally – any pelvic pathology (eg, bladder tumor, enlarged prostate, free pelvic fluid, pelvic abscess). 36

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

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EXHIBIT A

Transabdominal & Transvaginal US • If order states Pelvic US, and both transabdominal and transvaginal are performed can both be coded? – If a T/A US does not yield an adequate examination (i.e. ovaries and adnexa not visualized due to superimposed distended gas-filled loops of bowel) a T/V exam is medically necessary to fully evaluate the ovaries and adnexa • Code the T/V study (76830) in addition to the T/A study 37

What is a duplex scan? • Combines Doppler and conventional ultrasound – Conventional US: view structure of blood vessels – Doppler US: view movement and speed of blood through the vessels

• Duplex ultrasound produces images that can be color coded to show physicians where blood flow is blocked 38

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

US & Duplex – To Code or Not to Code? • Doppler studies should NOT be routinely performed and billed in conjunction with US • When it is medically necessary to perform a vascular study in conjunction with ultrasound of an organ, it is appropriate to report the vascular study separately, however, – to code a duplex study, true vascular analysis needs to be performed. – duplex should not be coded when color is just turned on to determine if a structure is vascular 39

Ultrasound & Duplex • NCCI edits allow -59 modifier • Edits designed to prevent inappropriate use of the noninvasive Doppler imaging codes – when Doppler is performed with a real-time US study for anatomical structure identification – where an evaluation of blood flow is performed for a valid medical reason in addition to gray scale evaluation, billing of both CPT codes is justified.

Source: ACR Coding Source, Nov/Dec 2005

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

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EXHIBIT A

Ultrasound & Duplex • CMS does NOT consider US exams to be components of duplex scans. • The column 1 and column 2 coded procedures are generally performed for different clinical scenarios although there are some instances where both procedures may be necessary.

Source: ACR Coding Source, Nov/Dec 2005

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US & Duplex - Orders • Documentation of an order from a physician for both examinations should be maintained. – Hospital setting the ordering physician may be the radiologist. – An order from the referring physician is required in the freestanding (nonhospital) and IDTF setting. Source: ACR Coding Source, Nov/Dec 2005

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

Ultrasound & Duplex • The 20 code pairs requiring modifier -59: 93975 76700

93976 76700

93978 76770

93979 76770

93975 76705

93976 76705

93978 76775

93979 76775

93975 76770

93976 76770

93978 76986

93975 76775

93976 76775

93975 76856

93976 76778

93975 76778

93976 76986

93979 76856 93979 76986

93975 76986

Source: ACR Coding Source, Nov/Dec 2005

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Ultrasound & Duplex (cont.) PROCEDURE: US SCROTUM & CONTENTS FINDINGS: Real-time imaging reveals the right testicle to measure 2.7 x 4.2 x 3.2 cm and show normal echo texture. The right epididymis measures 1.0 cm and appears intact. Color flow Doppler imaging demonstrates normal flow to the epididymis and testicle. Real-time imaging reveals the left testicle to measure 2.5 x 4.3 x 3.1 cm and demonstrates normal echo texture. The left epididymis measures 1.4 cm and appears intact. Color flow Doppler imaging demonstrates normal flow to the epididymis and testicle. There is persistence of the small left varicocele which is unchanged from the prior examinations of 11/08/04 and 04/09/04. A small left hydroceles and benign appearing calcifications are stable.

What CPT code(s) should be assigned? 44

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

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EXHIBIT A

Ultrasound Guidance • Is the radiologist required to state in the report "permanent images are stored"? – Radiologist is required to dictate a statement about the localization process, eg, ultrasound guidance was used for needle placement, NOT that permanent images are stored. – “Permanent images" should be retrievable in the event of a practice audit.

Source: ACR Coding Source, Jan/Feb 2005

45

Ultrasound Guidance • CPT 2005 clearly states that permanent images of the target area are required when imaging guidance is utilized. • Limited sonography of the target area is included in imaging guidance codes.

Source: ACR Coding Source, Sept/Oct 2005

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

US w/ US Guidance • Patient presents with an order for an USguided thoracentesis or paracentesis and the technologist performs a limited US to evaluate how much fluid (if any) is present and in which location. – Is it appropriate to charge a limited diagnostic US in addition to the guidance and procedure code? Source: ACR Coding Source, Sept/Oct 2005

47

US Guidance – Vascular Access • CPT code 76937 specifically lists the requirements for using this code: – ultrasound evaluation of the potential access sites – documentation of selected vessel patency – concurrent real-time ultrasound visualization of vascular needle entry – permanent recording and reporting. 48

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

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EXHIBIT A

CT vs. CTA • Computed tomographic angiography is a less invasive technique for imaging vessels that has gained widespread use in clinical practice. The information obtained from the CTA is used in the evaluation of vascular anatomy • Imaging of the vessels is not necessarily a CTA. The key distinction between CTA and CT is that CTA includes reconstruction post-processing of angiographic images and interpretation. If reconstruction postprocessing is not done, it is not a CTA study. Source – AMA CPT Assistant, Volume 11, Issue 7, July 2001 49

CT vs. CTA • Injection of contrast material is part of the “with contrast” CTA procedure; it is not appropriate to separately report the code for the administration of contrast • The supply of contrast may be reported separately with CPT code 99070 or with the appropriate HCPCS Level II code for the contrast material used • Typically a noncontrast sequence(s) is performed for localization; this is indicated in the “ without” component of the CTA code and is not separately reported • Evaluation of source images is an inclusive component of the CTA interpretation • Administration of oral and/or rectal contrast alone does not qualify as a study “with contrast” and are not typically used in CTA since they tend to obscure the vasculature. Source – AMA CPT Assistant, Volume 11, Issue 7, July 2001 50

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Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

CT vs. CTA (cont.) • Patient presents with hip fracture and shortness of breath; evaluate artery for possible pulmonary embolism. – A contrast enhanced CT of the chest is performed and tailored to evaluate the pulmonary arterial circulation for presence of pulmonary emboli. No angiographic reformatted images are obtained. – Is this a CT or a CTA? Source – AMA CPT Assistant, Volume 11, Issue 7, July 2001 51

CT vs. CTA (cont.) • This example illustrates a contrast enhanced CT of the chest rather than a CTA, and should be reported as 71260.

Source – AMA CPT Assistant, Volume 11, Issue 7, July 2001 52

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

27

EXHIBIT A

Coronary CT and CTA • ACR, ACC, and BCBS worked together to create several new Category III CPT codes for 2006 describing various common combinations of cardiac CT and CTA studies • This structure allows, in most cases, for a single code to describe the combination of services performed. • For more information on these and other Category III codes, see http://www.amaassn.org/ama/pub/category/3885.html

53

Coronary CT and CTA (cont.) • Eight new Category III codes have been created to report cardiac CT and CTA for: – Coronary calcium evaluation (“calcium scoring”) – Coronary CTA (CT Coronary Angiography) – CT evaluation of cardiac structure, morphology, function and vasculature

54

28

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

Coronary CT and CTA (cont.) • As of January 1, 2006, the Category III codes must be used to report these studies since they accurately describe the procedure performed. • This is both a CPT and a HIPAA Requirement! http://www.cms.hhs.gov/hipaa/hipaa2/regulations/transactio ns/default.asp http://www.hipaadvisory.com/action/Compliance/TransCodeSetsGuide.htm

55

Coronary CT and CTA (cont.) • Cardiac Computed Tomography (CT) and Computed Tomographic Angiography (CTA) – See Category III Codes 0144T – 0150T (and add-on code 0151T) to report various types of cardiac CT and CTA examinations – Report the appropriate code(s) based on whether coronary CT, CTA and/or calcium scoring is performed – If function evaluation is performed (left & right ventricular function, ejection fraction, and segmental wall motion), report add-on code 0151T Do not separately report 3D rendering

56

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

29

EXHIBIT A

3D Rendering – 76376/76377 • 76375 Deleted for 2006 • 2D no longer separately billable – Coronal – Sagittal – Multiplanar – Oblique reformats

from 2D axial images Source: Clinical Examples in Radiology, Volume 2, Issue 1: Winter 2006 57

3D Rendering – 76376 / 76377 (cont.) •

76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post-processing on an independent workstation

•

76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post-processing on an independent workstation

•

Require concurrent physician supervision of image post processing 3D manipulation of volumetric data set and image rendering

•

Should not be reported in conjunction with CTA, MRA, PET, CT colonography, nuclear medicine codes or the Category III cardiac CT/CTA codes. 58

30

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

3D Rendering – 76376 / 76377 (cont.) • New codes represent complex renderings: – Shaded surface – Volumetric rendering – Quantitative analysis (segmental volumes and surgical planning) – Maximum Intensity Projections (MIP)

• Performed on scanner or independent workstation

Source: Clinical Examples in Radiology, Volume 2, Issue 1: Winter 2006 59

3D Rendering – 76376/76377 (cont.) • Method of reformatting • Physician Supervision – What does “concurrent” mean? – What does Medicare require?

• Required documentation – Test order • Do I need an order from the referring doctor to bill for 3D rendering?

– Radiology Report • Must the radiology report state “3D images acquired” or “3D images acquired on independent workstation”? Source: Clinical Examples in Radiology, Volume 2, Issue 1: Winter 2006

60

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

31

EXHIBIT A

Contrast Materials • “With contrast" refers to contrast administered: – Intravascularly – Intra-articularly – Intrathecally • Injection of IV contrast is part of the "with contrast" - CT, CTA, MRI, and MRA procedures. – For intra-articular injection, use the appropriate joint injection code. – For spine examinations "with contrast" includes intrathecal or intravascular injection. For intrathecal injection, use also 61055 or 62284 • Oral and/or rectal contrast administration alone does not qualify as a study "with contrast." 61

Contrast Coding & Documentation • • • • •

Route of administration Type Concentration Amount Injecting the material is “bundled”, however the appropriate HCPCS code should be assigned for the contrast 62

32

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

Supervision and Interpretation • Radiological supervision and interpretation (RS&I) codes require just that – both supervision and interpretation by the radiologist • If either supervision or interpretation is not performed, append a modifier -52 to the RS&I code 63

PET & PET/CT • We have a PET/CT Integrated System and the referring physician’s initial order states PET study. Can we perform and bill a PET/CT?

Source: SNM Comments/Guidelines for PET/CT with Integrated Systems, July 2005

64

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

33

EXHIBIT A

PET & PET/CT (cont.) • We have a PET/CT Integrated System. A referring physician has ordered a diagnostic CT & a PET/CT for anatomic localization on the same day. Our current PET/CT integrated system is capable of performing diagnostic CTs. How are these studies coded?

Source: SNM Comments/Guidelines for PET/CT with Integrated Systems, July 2005 65

PET & PET/CT (cont.) • If a PET/CT and a diagnostic CT are performed on the same day, how are these studies coded?

Source: ACR Coding Source, July/Aug 2005

34

66

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

PET & PET/CT (cont.) • Who can make the determination that a PET/CT and a diagnostic CT are required?

Source: ACR Coding Source, July/Aug 2005

67

PET & PET/CT (cont.) • We have a PET only system, but we acquire a CT for fusion following the PET scan. Can we use the PET/CT CPT codes 78814-78816?

Source: SNM Comments/Guidelines for PET/CT with Integrated Systems, July 2005 68

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

35

EXHIBIT A

PET & PET/CT (cont.) • Additionally, we are fusing PET scans with both CT and MRI studies NOT acquired concurrently with integrated systems, how do we code for these studies including the fused images?

Source: SNM Comments/Guidelines for PET/CT with Integrated Systems, July 2005 69

PET & PET/CT (cont.) • Can I report 3D rendering in addition to a PET and PET/CT for anatomic localization procedure if the report documents this was completed? • Do I code and bill separately using CPT or HCPCS Level II codes for the PET radiopharmaceuticals? Source: SNM Comments/Guidelines for PET/CT with Integrated Systems, July 2005 70

36

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

Mammography Test Orders • Screening Mammography – Performed on an asymptomatic female – At a minimum CC & MLO views are obtained of each breast.

• Diagnostic Mammography – called problem-solving mammography or consultative mammography. – Performed because there is a reasonable suspicion that an abnormality may exist in the breast – Additional views performed for diagnostic mammography The patient’s physician determines which type of exam is appropriate. 71

Post Procedure Mammograms • Is it appropriate to code for a mammogram following a vacuum-assisted, imageguided biopsy and tissue marker placement? – Depends on the modality used – Depends on the number of physicians involved

72

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

37

EXHIBIT A

Outpatient Coding Guidelines

73

Coding Guidelines • Use the ICD-9-CM code that describes the patient’s diagnosis, symptom, compliant, condition, or problem. Do not code a suspected diagnosis. • Use the ICD-9-CM code that is chiefly responsible for the item or service provided. • Assign codes to the highest level of specificity. • Code chronic conditions when they apply to the patients treatment and code all documented conditions that affect treatment at the visit. • Do not code conditions that no longer exist. 74

38

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

Coding Guidelines (cont.) • Most of the time Medicare utilizes the primary ICD-9 code to make a medical necessity determination • Use the following guidelines to assign the primary diagnosis code – Code a diagnosis confirmed by test results – Code signs/symptoms when findings are normal or when the findings are uncertain (ie. Probable, suspected, questionable) – Do not code incidental findings or unrelated co-existing conditions – For screening tests (those performed in the absence of signs/symptoms) assign the appropriate V code (findings are coded as secondary) 75

Coding FAQs • Can I code from the header of the radiology report? – Must the body of the report support the exam stated in the header?

• If a radiologist uses the phrase “consistent with” in his report can I code the condition as a definitive diagnosis? – Coding Clinic, 3rd Quarter 2005 76

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

39

EXHIBIT A

“Pecking” Order for ICD-9 Coding • Radiology Report – Findings – Indications

• Test orders

77

Medical Necessity

78

40

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

What is medical necessity? • Medicare defines medical necessity as a determination of a service that is reasonable and necessary for the diagnosis of illness or injury. – Medicare covers only those services that are reasonable and necessary – Medicare requires all providers to report information regarding the patient’s diagnosis when seeking payment to determine whether services ordered were medically necessary. 79

Covered vs. Non-Covered Services Non-Covered: • • •

Never covered by a third party regardless of diagnosis or circumstances. Medicare documents non-covered services in Section 1862 of the Social Security Act. Other third party payers make individual determinations on which services are non-covered.

Covered: • • •

May be either preventative or diagnostic. Can be either medically necessary or not medically necessary. Payers provide written coverage guidelines for specific procedures, usually in the form of Local Medical Review Policies, to determine whether or not services are medically necessary.

80

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

41

EXHIBIT A

Performing a Medical Necessity Check • Determine whether the test/service has an NCD or LCD • If the test/service does not have limited coverage under NCD or LCD proceed with test • If test/service does have limited coverage under NCD or LCD, review the signs/symptoms or diagnosis that prompted the test to be ordered • If the test/service provided does not meet medical necessity requirements and/or the s/s or dx is not on the list of covered ICD-9 codes, complete an ABN • For those tests with frequency limitations, review the appropriate section of the coverage determination and obtain an ABN when frequency is exceeded. 81

Advance Beneficiary Notice CMS has published two official ABNs: • CMS-R-131-G—use this for any services, including lab services. – This form can be customized in the “Items or Services” and “Because” boxes, and in the header.

• CMS-R-131-L—use this only for lab services, usually at a freestanding diagnostic laboratory testing facility. – This form can be customized in the header and in the “Reasons and Tests” three- column box area. 82

42

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

Improving Physician Documentation

83

Working With Physicians •

What do they need to know? - Documentation guidelines per CPT and ACR

•

Standard Complaints - “Documentation takes time away from patient care” - “Compliance and correct coding do not contribute to the quality of patient care”

These statements are NOT TRUE! Good documentation is critically important to patient care. 84

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

43

EXHIBIT A

Working With Physicians (cont.) • Identify a physician “champion” to assist in physician education - Physicians are more likely to consider messages coming from

another physician

• Identify and address documentation errors right away - Timely discussion facilitates front-end correct claims and instills a sense of urgency and importance

• Differentiate between “clinical speak” and “code speak” - Educate as to what coders need in order to make distinctions

between medical terms (e.g. sepsis and urosepsis) Source: HCPro’s Briefings on Coding and Compliance Strategies, February 2002

85

Working With Physicians (cont.) • Address doctors directly - Look them in the eye - Offer privacy and convenience - Keep them involved: Welcome physicians’ input and let them know it is valuable - Never react back - Don’t be intimidated!

• Make an Impression – Just the facts Personal responsibility/liability Financial impact (money talks!) 86

44

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT A

Working With Physicians (cont.) • Nothing has worked – Now What? - Disciplinary action Develop an improvement tool (such as a form) to document issues areas of concern Form should be completed and submitted to disciplinary committee (medical director, chief radiologist, physician champion) for review and discussion of possible resolution 87

For additional information visit: http://www.seradmgt.com/CodingReimbursement.html • • • • •

SNM FAQ’s Modifier -59 Diagnostic Test Order FAQs ICD-9 Coding for Diagnostic Tests Mammography Test Order Criteria

http://www.seradmgt.com/internet.html • ACR Guidelines for Diagnostic Communication • Medicare Claims Processing Manual

88

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

45

EXHIBIT A

Q&A

Stacie Buck

Email: [email protected]

Stacy Gregory

Email: [email protected] 89

46

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

Exhibit B Medicare’s Requirements for Ordering Diagnostic Tests

Source: Stacie L. Buck, RHIA, LHRM. Reprinted with permission.

EXHIBIT B

Southeast Radiology Management Management Ⱦ Billing Ⱦ Compliance Ⱦ Audits www.seradmgt.com

Medicare’s Requirements for Ordering Diagnostic Tests Does the referring physician need to include signs/symptoms or a diagnosis? Yes, section 4317(b) of the Balanced Budget Act (BBA), requires referring physicians to provide this diagnostic information to the testing entity at the time the test is ordered. If the referring physician indicates a “rule out”, he/she must also include signs/symptoms prompting the exam for the “rule out” condition. What constitutes an order? An "order" is a communication from the treating (referring) physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may include the following forms of communication: i i i

A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility; A telephone call by the treating physician/practitioner or his/her office to the testing facility; and An electronic mail by the treating physician/practitioner or his/her office to the testing facility.

If the order is communicated via telephone, both the treating (referring) physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records. The treating (referring) physician/practitioner must order all diagnostic tests furnished to a beneficiary who is not an institutional inpatient or outpatient. A testing facility that furnishes a diagnostic test ordered by the treating physician/practitioner may not change the diagnostic test or perform an additional diagnostic test without a new order. This policy is intended to prevent the practice of some testing facilities to routinely apply protocols which require performance of sequential tests. When the testing facility or radiologist determines that an ordered diagnostic test is clinically inappropriate or suboptimal and that a different diagnostic test (e.g. MRI instead of CT) should be performed, can the testing facility or radiologist modify the order? No, the interpreting physician/testing facility may not perform the unordered test until a new order from the treating physician/practitioner has been received. What happens when the results of an ordered diagnostic test are normal and the interpreting physician believes that another diagnostic 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)? An order from the treating physician must be received prior to performing the unordered diagnostic test. Are there any exceptions to the rules for modifying test orders? Yes, there are four exceptions to the rules. These exceptions apply to an interpreting physician of a testing facility who furnishes a diagnostic test to a beneficiary who is not a hospital inpatient or outpatient. The interpreting physician must document accordingly in his/her report to the treating physician/practitioner. Created by: Stacie L. Buck, RHIA, LHRM Vice President, Southeast Radiology Management

48

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT B

Southeast Radiology Management Management Ⱦ Billing Ⱦ Compliance Ⱦ Audits www.seradmgt.com

The first exception concerns additional testing. 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: i i i i i

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 his/her report why additional testing was done.

Examples: i i

The last cut of an abdominal CT scan with contrast shows a mass requiring a pelvic CT scan to further delineate the mass; A bone scan reveals a lesion on the femur requiring plain films to make a diagnosis.

The second exception applies to test design. Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test (e.g., number of radiographic views obtained, thickness of tomographic sections acquired, use or non-use of contrast media The third exception is clear error. The interpreting physician may modify, without notifying the treating physician/practitioner, an order with clear and obvious errors that would be apparent to a reasonable layperson, such as the patient receiving the test (e.g., x-ray of wrong foot ordered). The fourth exception is patient condition. The interpreting physician may cancel, without notifying the treating physician/practitioner, an order because the beneficiary's physical condition at the time of diagnostic testing will not permit performance of the test (e.g., a barium enema cannot be performed because of residual stool in colon on scout KUB; PA/LAT of the chest cannot be performed because the patient is unable to stand). When an ordered diagnostic test is cancelled, any medically necessary preliminary or scout testing performed is payable.

Created by: Stacie L. Buck, RHIA, LHRM Vice President, Southeast Radiology Management

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

49

Exhibit C Incomplete Test Orders Tracking Sheet

Source: Stacie L. Buck, RHIA, LHRM. Reprinted with permission.

EXHIBIT C

Incomplete Test Orders Tracking Sheet

This form should be completed in the event that a patient arrives with a prescription without required diagnostic information (i.e. signs/symptoms, narrative diagnosis, or ICD-9 code), or a prescription that states “rule out” with no presenting signs/symptoms. The referring physician office must be contacted for the required diagnostic information.

THIS FORM IS NOT TO BE USED TO TAKE VERBAL ORDERS FOR TESTING. All tests should be ordered in writing directly from the referring physician.

Testing Information Patient Name: Referring Physician: Date of Exam: Type of Exam:

Phone Call Log Date & Time of Call: Name of person providing information: Signs/Symptoms or Diagnosis: Other information required: __________________________________ When contacting the referring physician, ask to have a new prescription faxed over that contains all required information. Notes:

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

51

Exhibit D ICD-9-CM Coding Requirements for Diagnostic Tests

Source: Stacie L. Buck, RHIA, LHRM. Reprinted with permission.

EXHIBIT D

Southeast Radiology Management Management Ⱦ Billing Ⱦ Compliance Ⱦ Audits www.seradmgt.com

ICD-9-CM Coding Requirements for Diagnostic Tests CMS requires following the ICD-9-CM Coding Guidelines for Outpatient Services (hospital-based and physician office). These guidelines instruct physicians to report diagnoses based on test results, if available. Health care providers must comply with the following instructions in determining the appropriate ICD-9-CM diagnoses code for diagnostic test results. These instructions simplify coding for diagnostic tests consistent with the ICD-9-CM Guidelines for Outpatient Services (hospital-based and physician office). General rules for reporting diagnosis codes on the claim are: i Use the ICD-9-CM code that describes the patient’s diagnosis, symptom, complaint, condition or problem. Do not code suspected diagnosis. i Use the ICD-9-CM code that is chiefly responsible for the item or service provided. i Assign codes to the highest level of specificity. Use the fourth and fifth digits where applicable. i Code a chronic condition as often as applicable to the patient’s treatment. i Code all documented conditions that coexist at the time of the visit that require or affect patient care or treatment. (Do not code conditions that no longer exist.) Determining the Appropriate Primary ICD-9-CM Diagnosis Code for Diagnostic Tests Ordered Due to Signs and/or Symptoms Confirmed Diagnosis Based on Results of Test 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. Example: A patient is referred to a radiologist for an abdominal CT scan with a diagnosis of abdominal pain. The CT scan reveals the presence of an abscess. The radiologist should report a diagnosis of “intra-abdominal abscess.” If the individual responsible for reporting the codes for the testing facility or the physician’s office does not have the report of the physician interpretation at the time of billing, the individual responsible for reporting the codes for the testing facility or the physician’s office should code what they know at the time of billing. Sometimes reports of the physician’s interpretation of diagnostic tests may not be available until several days later, which could result in delay of billing. Therefore, in such instances, the individual responsible for reporting Created by: Stacie L. Buck, RHIA, LHRM Vice President, Southeast Radiology Management

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

53

EXHIBIT D

Southeast Radiology Management Management Ⱦ Billing Ⱦ Compliance Ⱦ Audits www.seradmgt.com the codes for the testing facility or the physician’s office should code based on the information/ reports available to them, or what they know, at the time of billing. Signs or Symptoms 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. Example: A patient is referred to a radiologist for a spine x-ray due to complaints of “back pain.” The radiologist performs the x-ray, and the results are normal. The radiologist should report a diagnosis of “back pain” since this was the reason for performing the spine x-ray. 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. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician. Example: A patient is referred to a radiologist for a gastrograffin enema to rule out appendicitis. However, the referring physician does not provide the reason for the referral and is unavailable at the time of the study. The patient is queried, indicates that he/she saw the physician for abdominal pain, and was referred to rule out appendicitis. The radiologist performs the x-ray, and the results are normal. The radiologist should report the abdominal pain as the primary diagnosis. If the physician’s interpretation of the test result is not clear or is ambiguously stated in the patient’s medical record, either the attending physician or the physician that performed that test should be contacted for clarification. This may result in the reporting of symptoms or a confirmed diagnosis. Diagnosis Preceded by Words that Indicate Uncertainty If the results of the diagnostic test are normal or nondiagnostic and the referring physician records a diagnosis preceded by words that indicate uncertainty (e.g., probably, 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. Diagnoses labeled as uncertain are considered by the ICD-9-CM Coding Guidelines as unconfirmed and should not be reported. This is consistent with the requirement to code the diagnosis to the highest degree of certainty.

Created by: Stacie L. Buck, RHIA, LHRM Vice President, Southeast Radiology Management

54

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

EXHIBIT D

Southeast Radiology Management Management Ⱦ Billing Ⱦ Compliance Ⱦ Audits www.seradmgt.com Example: A patient is referred to a radiologist for a chest x-ray with a diagnosis of “rule out pneumonia.” The radiologist performs a chest x-ray, and the results are normal. The radiologist should report the sign(s) or symptom(s) that prompted the test (e.g., cough). Incidental Findings Incidental findings should never be listed as primary diagnoses. If reported, incidental findings may be reported as secondary diagnoses by the physician interpreting the diagnostic test. Example: A patient is referred to a radiologist for an abdominal ultrasound due to jaundice. After review of the ultrasound, the interpreting physician discovers that the patient has an aortic aneurysm. The interpreting physician reports jaundice as the primary diagnosis and may report the aortic aneurysm as a secondary diagnosis because it is an incidental finding. Example: A patient is referred to a radiologist for a chest x-ray because of wheezing. The x-ray is normal except for scoliosis and degenerative joint disease of the thoracic spine. The interpreting physician reports wheezing as the primary diagnosis since it was the reason for the patient’s visit and may report the other findings (scoliosis and degenerative joint disease of the thoracic spine) as additional diagnoses. Unrelated Coexisting Conditions/Diagnoses Unrelated and coexisting conditions/diagnoses may be reported as additional diagnoses by the physician interpreting the diagnostic test. Example: A patient is referred to a radiologist for a chest x-ray because of a cough. The result of the chest x-ray indicates the patient has pneumonia. During the performance of the diagnostic test, it was determined that the patient has hypertension and diabetes mellitus. The interpreting physician reports a primary diagnosis of pneumonia. The interpreting physician may report the hypertension and diabetes mellitus as secondary diagnoses. Diagnostic Tests Ordered in the Absence of Signs and/or Symptoms When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness or injury, the testing facility or the physician interpreting the diagnostic test should report the screening code as the primary diagnosis code. Any condition discovered during the screening should be reported as a secondary diagnosis. Example: A patient is referred to a radiologist for a chest x-ray as part of a routine physical. The result of the chest x-ray indicates a lung mass. The interpreting physician reports the appropriate screening code as the primary diagnosis and reports the lung mass as a secondary diagnosis. Created by: Stacie L. Buck, RHIA, LHRM Vice President, Southeast Radiology Management

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

55

Exhibit E Ordering Mammograms: Screening vs. Diagnostic

Source: Stacie L. Buck, RHIA, LHRM. Reprinted with permission.

EXHIBIT E

Southeast Radiology Management Management Ⱦ Billing Ⱦ Compliance Ⱦ Audits www.seradmgt.com

Ordering Mammograms: Screening vs. Diagnostic Screening Mammography Screening mammography is performed on an asymptomatic female that has not manifested any clinical signs, symptoms, or physical findings of breast cancer. CC & MLO views are obtained of each breast.

9

If the patient is currently asymptomatic, most likely a screening mammogram is clinically appropriate.

Effective July 1, 2005 V76.11 is approved for use for submitting claims to Medicare for screening mammograms. CMS considers the following patients to be high risk: x Has a personal history of breast cancer (V10.3) x Has a family history of breast cancer - a mother, sister, or daughter who has breast cancer (V16.3) x Had her first baby after age 30 (V15.89) x Has never had a baby. (V15.89)

9

If the patient meets one or more of the criteria above, please indicate V76.11, “Special screening for malignant neoplasm, screening mammogram for high-risk patient” on the order for a screening mammogram, plus the appropriate V-code noted above.

9

If the patient does not meet any of the criteria above, please indicate V76.12, “Special screening for malignant neoplasm, other screening mammography” on the order for a screening mammogram.

Diagnostic Mammography Diagnostic mammography is also called problem-solving mammography or consultative mammography. A diagnostic mammogram is performed because there is a reasonable suspicion that an abnormality may exist in the breast. Additional views are performed for a diagnostic mammogram. Diagnostic mammograms are clinically appropriate under the following circumstances: x Clinical signs, symptoms, or physical findings suggestive of breast cancer. x An abnormal or questionable screening mammogram. x A personal history of breast cancer. x A personal history of biopsy-proven benign breast disease. x A woman is asymptomatic, but based on her history and other factors the physician considers significant, the physician’s judgment is that a diagnostic mammogram is appropriate

9

If the patient meets one or more of the above conditions, request a diagnostic mammogram with the appropriate indications documented on the order.

Created by: Stacie L. Buck, RHIA, LHRM Vice President, Southeast Radiology Management

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

57

Exhibit F Modifier -59 Decision Tree

Source: Stacie L. Buck, RHIA, LHRM. Reprinted with permission.

Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement

-DQ

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'RQRW XWLOL]H PRGLILHU

< H V

,VDQRWKHUPRGLILHU RWKHUWKDQPRUH DSSURSULDWH"

< H V

,VDPRGLILHUDOORZHG" &KHFN&&,LQGLFDWRUV  1R