August 2007 Vol. 4, No. 8

Use these tips to write better business memos Good writing takes practice. Those who ignore this fact must face the wrath of staff members frustrated with the poor communication often found in radiology memos. Whether you realize it or not, you write every day. And through these seemingly mundane memos, e-mails, policy changes, and audit reports, you create important documents that relay the fates and fortunes of your radiology facility and its staff members. According to Paul Larson, president of Paul Larson Communications in Evanston, IL: ➤ The best writing is simple ➤ The best words are short ➤ The best writers are organized “We feel we have to overcomplicate our writing,” said Larson, who spoke at the Radiology Business Management Association annual conference in St. Louis in May. “It’s a curse of the 21st century. We seem to think In this issue

if we don’t use big words then our memo, or letter, or policy change won’t seem important enough.”

Learn the simple rules In healthcare, as elsewhere, nearly every manager tends to convolute the written word, Larson said. Certainly, no one expects

“It’s a curse of the 21st

you to compose

century. We seem to think

Shakespearian

if we don’t use big words,

sonnets about the next radiology coding com-

then our memo, or letter, or policy change won’t seem important enough.”

pliance policy

—Paul Larson

change. (Why write “One must expect that the general population of the genus Rosa tends to cultivate at least one barb” when you could write “Every rose has its thorn”?) But your staff members expect you to communicate changes effectively. Larson said written communications should: ➤ Stay concise by eliminating fancy words; qualifying or modifying words; and clichés, superlatives, and jargon ➤ Avoid the passive voice ➤ Use action verbs

p. 3 Ask the Insider

CMS’ Transmittal 66 attempts to clarify payment for services provided overseas. Our experts interpret the effect on teleradiology. p. 5 CMS set to roll out new ABN form

Learn how changes to the advanced beneficiary notice (ABN) affect your radiology facility.

Get organized Organize your thoughts prior to putting your pen to paper. It will improve your writing significantly. No amount of polishing can mend a poorly crafted document. Follow Larson’s steps to organize what’s on your

p. 6 Assess compliance awareness with regular reviews

Determine whether staff members use your compliance program on a regular basis with a simple analysis during regular appraisals. p. 7 Coding corner

Melody Mulaik offers tips for picking the right cardiac CT codes.

mind and communicate it on paper: 1. Form your big idea. Always have a theme. If you don’t know exactly what you want to say, it will be impossible for you to write a strong document. 2. Know your audience. Figure out who you want to read your document. Executives, ­technologists, > continued on p. 2

Radiology Administrator‘s Compliance & Reimbursement Insider

Page 

Better memos

August 2007

< continued from p. 1

­radiologists, vendors, and the general public all approach

Create a thought bucket

data from different perspectives. Create your document

Visualize your point by sketching out your memo.

with your specific audience in mind. Explain the items

Put your “big idea” in the center of the page, and sur-

that the particular audience needs to know about most.

round it with the things that you need to say. Create

3. Make your point. Explain the three or four most im­­

buckets of common thoughts or messages. Put every-

portant points that you need to make. “Remember the

thing that’s similar into its proper bucket. Position these

rule of threes,” Larson said. “Readers and listeners gen-

buckets around the big idea, and include supporting data

erally aren’t able to absorb groups of more than three.

and other information.

So try to limit your message to two or three essential

Now, think about the beginning, middle, and end of

points whenever possible.” Also, tell your audience

your document. Introduce your main idea, and then sup-

what you want them to do. Big business experts call

port it with examples, documentation, and information.

this the ‘call to action’ or ‘action items.’

Explain why your main idea is important. Conclude your

Editorial Advisory Board

Radiology Administrator’s Compliance & Reimbursement Insider

document with what you want your audience to do with the information you just provided.

Group Publisher: Lauren McLeod Executive Editor: Melissa Osborn Managing Editor: Melissa Varnavas Larry Balmer Radiology Incorporated Mishawaka, IN Stacie L. Buck, RHIA, CCS-P, LHRM, RCC Southeast Radiology Management Stuart, FL

Melody W. Mulaik, MSHS, CPC, CPC-H, RCC Coding Strategies, Inc. Powder Springs, GA Claudia A. Murray Provider Practice Analysis, LLC Baldwin, MD

Mark B. Canada, MHA, CPC Medical Practice Management Richmond, VA

Paula Richburg QuadraMed Columbia, MO

Alice Gosfield, Esq. Alice G. Gosfield & Assocs., PC Philadelphia, PA

William A. Sarraille, Esq. Sidley Austin Brown & Wood Washington, DC

Thomas W. Greeson, Esq. Reed Smith, LLP Falls Church, VA

Michael F. Schaff, Esq. Wilentz Goldman & Spitzer Woodbridge, NJ

Stacy Gregory, RCC, CPC Gregory Medical Consulting Services Tacoma, WA

Jay Silverman, Esq. Ruskin Moscou Faltischek, PC Uniondale, NY

Mark B. Langdon Arent Fox, PLLC Washington, DC

Edward Townley Moncrief Cancer Center Fort Worth, TX

Jackie Miller, RHIS, CPC Coding Strategies, Inc. Powder Springs, GA

Tobin N. Watt, Esq. Smith Helms Murliss & Moore, LLP Atlanta, GA

Diane S. Millman, Esq. Powers Pyles Sutter & Verville Washington, DC

Radiology Administrator’s Compliance & Reimbursement Insider (ISSN: 1527-2338) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $249/year; back issues are available at $25 each. • Postmaster: Send address changes to Radiology Administrator’s Compliance & Reimbursement Insider, P.O. Box 1168, Marblehead, MA 01945 • Copyright 2007 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail [email protected]. Visit our Web site at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the Marketing Department at the address above. • Opinions expressed are not necessarily those of Radiology Administrator’s Compliance & Reimbursement Insider. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. Radiology Administrator’s Compliance & Reimbursement Insider is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks.

Be concise Frequently, managers use too many words to describe a simple concept, Larson said. Take the following example of a recent radiology department memo: Going forward all current and future employees should operate within the hospital’s new basic radiology coding system regardless of departmental roles and relative job descriptions as this new computerized programming will allow the administration to track, audit, and report appropriate use and reimbursement of radiology procedures. Now consider the following, more readable version of the same memo: As of July 1, please use the new coding software. This new program provides better patient service and ensures that we get paid appropriately for the work we do. The latter version efficiently informs the reader of the important points, such as who (everyone), what (implementation of a new computer program), when (July 1), and why (to receive proper reimbursement). n Insider source Paul Larson, president, Paul Larson Communications, 1017 Greenleaf Street, Evanston, IL 60202, 647/475-1283; [email protected].

For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400. © 2007 HCPro, Inc.

August 2007

Radiology Administrator‘s Compliance & Reimbursement Insider

Page 

Ask the Insider

CMS transmittal clarifies some teleradiology confusion

Q

Here’s the scenario: A hospital contracts with a

nical component of the radiology service within the

radiology group to interpret radiology images.

United States, the payment limitation described in the

The hospital bills the technical portion, and the radiol-

­transmittal does not apply, says Aaron, who clarified the

ogy group bills the professional services. The radiol-

information with CMS representative Fred Grabau.

ogy group subcontracts with a service that employs a

So an American facility may bill for the technical

radiologist overseas to do a preliminary read for radiol-

component even if a radiologist interpreted the image in

ogy exams that the hospital performs after hours. The

another country as long as the hospital billed Medicare

radiology group then overreads the film and bills the

separately for the technical component.  

professional fee.

Medicare always had very limited coverage for services outside of the United States, says Regulatory Specialist

Does this arrangement between the radiologist and overseas provider make both the professional fee

Peggy S. Blue, MPH, CPC, of HCPro, Inc. “In fact, if it was not for the advent of telemedicine,

handled by the radiology group and technical fee billed

this transmittal would probably not have even been nec-

by the hospital not payable by Medicare? Or do the

essary,” Blue says. “I know it can be very attractive for

Medicare rules regarding reimbursement for overseas

patients to seek medical services in other countries due to

payments apply only to the services that the radiolo-

a significant cost savings in their out-of-pocket expenses,

gist provides, because that portion involves overseas

but I don’t see practitioners going that way.”

­services?

Change Request 5427, Medicare Benefit Policy A CMS Manual, Transmittal 66, amends Chapter 16, Section 60, of the manual to add the following paragraph:

However, for a variety of reasons, both radiology practices and hospital administrations increasingly look to overseas radiologists to perform the professional component of exams. Under these arrangements, the overseas physician

Payment may not be made for a medical service (or a por-

provides a preliminary read, and the United States–based

tion of it) that was subcontracted to another provider or

radiologist provides an overread.

supplier located outside the United States. For example, if a radiologist who practices in India analyzes imaging tests that were performed on a beneficiary in the United States,

The United States–based physician then bills Medi­ care for the interpretation of the exam. CMS has received several inquiries regarding wheth-

Medicare would not pay the radiologist or the U.S. facility

er radiologists providing professional interpretations in

that performed the imaging test for any of the services that

the United States can bill Medicare after receiving pre-

were performed by the radiologist in India.

liminary reads performed abroad.  However, CMS “has not yet decided whether it will

The payment limitation applies only to the portion

issue any guidance or clarification,” Aaron says. n

of the service furnished outside of the United States, says Hugh E. Aaron, MHA, JD, CPC, CPC-H, senior vice president of compliance and regulatory affairs/regulatory counsel for HCPro, Inc., in Marblehead, MA.  But if the radiology technologist performs the tech-

Insider sources Hugh E. Aaron, MHA, JD, CPC, CPC-H, senior vice president of compliance and regulatory affairs/regulatory counsel, HCPro, Inc., 200 Hoods Lane, Marblehead MA, 978/639-1872; [email protected]. Peggy S. Blue, MPH, CPC, regulatory specialist, HCPro, Inc., 200 Hoods Lane, Marblehead MA, 717/284-3479; [email protected].

For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400. © 2007 HCPro, Inc.

Radiology Administrator‘s Compliance & Reimbursement Insider

Page 

August 2007

Sample ABN

Source: CMS. Editor’s note: This is one of three sample forms that Medicare was considering as of presstime. For more information, visit www.cms.hhs.gov/PaperworkReductionActof1995.

For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400. © 2007 HCPro, Inc.

Radiology Administrator‘s Compliance & Reimbursement Insider

August 2007

Page 

CMS set to roll out new ABN form CMS announced several changes to the advanced beneficiary notice (ABN) in the February 23 Federal Register. Healthcare providers use ABNs to inform patients of their potential financial liability for services that Medicare won’t cover.

According to the draft, CMS’ goal is to “design a form that is clear and understandable for beneficiaries, while permitting appropriate customization by the various types of providers, practitioners, and suppliers that use ABNs.” Essentially, CMS wants to combine the two tradition-

CMS published a final draft of the proposed

al forms into one usable and easy-to-follow document,

changes on May 25 with the anticipation that these

said Bill Malm, president of Health Revenue Integrity

changes would take effect following the final 60-day

Services in Cleveland, who spoke during the HCPro, Inc.,

comment period and the subsequent approval of the

audioconference “Radiology ABNs: Ensure compliance

final rule.

and appropriate reimbursement” on June 13.

Changes include the: ➤ Combination of the general and lab-test versions of the ABN (CMS-R-131G and CMS-R-131-L, respectively) into one universal form ➤ Addition of the 800/MEDICARE phone number ➤ Addition of information regarding the patient’s right to demand that the provider bill Medicare

“This form could be used by different specialties, and it would be more user-friendly, with language the patient can understand,” Malm said. n Editor’s note: To view a draft of the new ABN, see the sample ABN on p. 4. To learn more, visit the CMS Web site and click on the Paperwork Reduction Act of 1995. Then click on PRA Listing and search for CMS-R-131.

➤ Additional option to allow beneficiaries to pay out of pocket for the procedure ➤ Additional description of the significance of the beneficiary’s signature

Insider source William L. Malm, ND, RN, president, Health Revenue Integrity Services, Inc., 815 Brick Mill Run, Westlake, OH 44145, 440/331-3312; wmalm.hris@ adelphia.net.

Tackle these topics prior to providing radiology ABNs

Q

A patient came to our facility for preoperative

Ensure compliance and appropriate reimbursement”

chest x-rays three days before surgery for cardiac

on June 13.

bypass. Should we have administered an advanced beneficiary notice (ABN)?

determine which payer provides coverage for A First the patient—Medicare, Medicaid, private, or com-

Most carriers, Balmer said, initially deny the preoperative chest x-ray claim. However, once they receive a claim with supporting documentation, carriers usually will reimburse for the exam. If dealing with a Medicare patient, check the local

mercial. Most insurers consider preoperative x-rays to

coverage determination for the procedure and deter-

be screening exams unless the scan helped surgeons

mine whether the exam meets medical necessity, said

gather information necessary for the operation, said

Bill Malm, president of Health Revenue Integrity

Larry Balmer, chief compliance officer at Radiology

Services in Cleveland, who also spoke during the

Incorporated in Mishawaka, IN. Balmer spoke during

­audioconference.

the HCPro, Inc., audioconference “Radiology ABNs:

> continued on p. 6

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Page 

Radiology ABNs

Radiology Administrator‘s Compliance & Reimbursement Insider

August 2007

< continued from p. 5

Only the Medicare program uses an ABN form. So, if Medicaid is the patient’s primary insurer, don’t use an ABN, said Malm. Consult the state Medicaid carrier to determine coverage requirements, he added. However, do not give an ABN to a non-Medicare

prior to the performance of a preoperative x-ray. Some states allow you to charge a patient for the service if he or she was presented with a choice. If you suspect that Medicaid won’t cover the preoperative x-ray, document that you informed the patient.

pa­­tient unless specifically required under a contractual

That way, if Medicaid denies the bill, you can bill the

arrangement with the non-Medicare payer, Malm said.

patient directly, Balmer said.

Although ABNs are specific to Medicare, some state

When dealing with situations involving questionable

Medicaid agencies, such as Indiana, require providers to

services and Medicaid, obtain an ABN as a blanket protec-

inform Medicaid patients about potential noncoverage of a

tion, said Malm. n

service. Further, many state groups encourage healthcare providers to make note in the medical record that the

Insider sources

facility told the patient about his or her fiscal liability.

Larry W. Balmer, CCP, compliance officer, Radiology Incorporated, 620 Edison Road, Suite 110, Mishawaka, IN 46545, 901/516-0818; lbalmer@ rad-inc.com.

Many payers require preauthorization, which precludes the necessity of an ABN. In that case, referring physicians must obtain permission or “preapproval”

William L. Malm, ND, RN, president, Health Revenue Integrity Services, Inc., 815 Brick Mill Run, Westlake, OH 44145, 440/331-3312; wmalm.hris@ adelphia.net.

Assess compliance awareness with regular staff reviews As you develop and implement your compliance

You can get some of your most valuable compliance

plan, look for every opportunity to generate employee

feedback when you sit down face-to-face with your radi-

feedback and reinforce your commitment to compli-

ology technologists and other staff members and discuss

ance. Take the pulse of your organization through con-

their concerns. If you go into each review with a prede-

versations with staff members. Periodic performance

termined set of compliance questions, you’re more likely

reviews (PPR)—those regularly scheduled staff apprais-

to get consistent feedback.

als—provide excellent opportunities to find out what’s going on. The Office of Inspector General says radiology manag-

Draft a list of questions and distribute it in a memo to all staff members who conduct performance reviews. A memo will instruct reviewers about how to incorpo-

ers should discipline employees who violate compliance

rate the compliance questions into their regular set of

policies and procedures. You need to find out whether

review inquiries.

your employees follow your policies and procedures and whether those policies and procedures are working first. For example, do employees have trouble under-

Sample questions 1. Do you keep a copy of our code of conduct

standing your policies and procedures? Do they mis-

and our compliance policies handy? Encourage em­­

takenly believe that those policies and procedures are

ployees to have compliance materials readily available at

unimportant?

their work stations or another easily accessible ­location.

Regular performance reviews are the most direct route to obtain answers about your compliance program.

Consider creative ways to keep these valuable tools within easy reach.

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August 2007

Radiology Administrator‘s Compliance & Reimbursement Insider

2. Have you ever consulted our code of conduct or compliance policies? Find out whether your staff members actually use your compliance resources

Page 

too difficult to understand and inappropriately complicate the healthcare routine. When an employee refers to this difficulty, press

in their day-to-day work. The best compliance plan in

him or her for examples of specific procedures and

the world isn’t worth anything if your employees don’t

request a detailed account of how staff members

use it.

attempt to work within the procedure and how he or

If they say they do use these compliance resources,

she deals with the problem. Such input will help you

find out how. Probe further to determine whether they

rewrite your policy and review complex procedures,

use the resources correctly, whether the resources are

making compliance easier throughout the radiology

helpful, or whether employees run into any difficulties

department or facility. n

when using the resources. 3. Are the compliance policies easy to under-

Editor’s note: The above excerpt is from the Radiology

stand? Do they help you do your job? Staff members

Manager’s Handbook: Tools and Best Practices for Business

sometimes believe compliance concerns are simply

Success. For information, visit www.hcmarketplace.com.

Coding corner

Determine the difference between CT and CTA by Melody W. Mulaik, MSHS, CPC, CPC-H, RCC

scanner and to identify the anatomic region to be evaluated during the ‘with contrast’ portion of the study.”

CTA has become a hot topic for radiology during the past few years. CTA reimbursement, equipment requirements, and joint venture relationships between cardiolo-

New CT scanners have more advanced technology that has nearly eliminated the need for calibration images. Clinical Examples in Radiology (volume one, issue three,

gists and radiologists for the interpretation of CTA have

summer 2005) also states, “When a localizer image is not

generated much discussion in the radiology community.

obtained, it is still appropriate to report the CTA pro-

Coders find it difficult to assign a CTA procedure

cedure codes. In such circumstances, a reduced service

code that accurately represents the service that the radi-

modifier is not required.” This clarification is important,

ologist performed according to the standard definition of

because many organizations have expressed concern that

CTA procedures.

the “without contrast” portion actually refers to diagnostic

By definition, all CTA procedure codes, except

images, contrary to the Coding Clinic definition. The bot-

the category III cardiac codes, include the following

tom line—if the exam occurs without initial noncontrast

­verbiage: “without contrast material(s), followed by

images, this does not change the code assignment.

contrast material(s) and further sections, including image postprocessing.”

Determining postprocessing Radiology coders and administrators face another

Coding by definition According to the AHA Coding Clinic for HCPCS (vol-

challenge, as well. Despite the fact that the radiologist, or radiology technologist, documents the procedure

ume five, number one, first quarter 2005), “the por-

in the report, the administrator or coder must ensure

tion of the CTA exam referred to as ‘without contrast

that the required “postprocessing” was performed and

material(s)’ represents the images taken to calibrate the

> continued on p. 8

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Radiology Administrator‘s Compliance & Reimbursement Insider

Page 

Coding corner

August 2007

< continued from p. 7

Understanding common confusions

­properly documented in that report. Imaging postprocessing refers to two-dimensional (2-

The most frequent coding mistake arises from CT

D) and/or three-dimensional (3-D) reconstruction(s) of

scans to evaluate for pulmonary embolism. Coding these

the CT data set acquired during the imaging process. The

as CTs or CTAs depends on the actual procedures that the

2-D reformatted images can be created in multiple planes

radiologist performed and documented.

(e.g., sagittal), then interpreted, annotated, and archived

If the radiologist performed the CT specifically for

as hard-copy and/or electronic files. The radiologist typi-

the purpose of viewing the pulmonary vessels and he

cally evaluates 3-D or volume-rendered reconstructions

or she performed image postprocessing (sagittal, coronal,

in multiple projections. The 3-D reformatting requires

2-D, 3-D, or multiplanar reconstructions), then it meets

extensive effort from the radiologist, who typically per-

the definition of a chest CTA (71275).

forms the processing on a separate workstation. The CPT

However, many CT scans that evaluate for pulmo-

Manual lists separate procedure codes for 3-D render-

nary embolism are not CTAs. They are simply CTs. The

ing (76376 and 76377); however, do not assign these in

radiologist must perform and document the image post-

addition to the CTA codes, because the CTA procedure

processing in order to bill for a CTA.

codes already include the work that these codes define. CT imaging of an anatomic region is not always

Discuss the “CT Pulmonary Embolism” protocol with radiologists and technologists to ascertain what

considered CT angiography, even if the primary concern

process they follow. Do not assign the procedure code

involves the blood vessels. The key distinction between

based on protocols, but by understanding the nuances

CT and CTA is that CTA includes image postprocessing,

of the actual procedure. Such awareness allows you to

such as maximum-intensity profile or 3-D renderings. A

provide feedback to the radiologist, if documentation is

CTA study includes:

inadequate, to ensure correct coding for the performed

➤ Acquisition of localizing images (if necessary)

procedure. n

➤ Acquisition of contrast-enhanced images ➤ Reformatting of those images (postprocessing)

Editor’s note: Mulaik is copresident of Coding Strategies,

➤ Interpretation of both the axial source images and

CodingStrategies.com.

the reconstructed images

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