HAP Radiology Billing and Coding Blog

This is the second in our series of articles designed to assist radiologists with the transition to ICD-10-CM, which will be used in place of ICD-9-CM for reporting diagnoses to Medicare beginning on October 1, 2015. Our goal is to help you fine-tune your documentation to assure the best coding and uninterrupted reimbursement under ICD-10. Our first article covered Documentation for Pain and we also previously posted other information to help radiology practices prepare for this major change.   A large number of diagnostic imaging exams deal with the assessment of fractures and the documentation of these exams will require some pieces of information that were not always included in radiology reporting until now.

By this time, most people working in healthcare are already aware of the deadline to begin using ICD-10-CM in place of ICD-9-CM for reporting diagnoses to Medicare on October 1, 2015. Healthcare Administrative Partners has previously posted information to help radiology practices prepare, and this new series of articles is designed to help radiologists fine-tune their documentation to assure the best coding and uninterrupted reimbursement under ICD-10. One of the major areas of concern for radiologists is in the description of pain for proper diagnosis coding. A survey of historical coding by radiology practices showed that 17 of the 100 most commonly used ICD-9 diagnoses were related to pain.

The use of 3D reconstruction along with CT imaging is quite common for many types of exams performed by radiology practices. In some cases it is a minimum requirement in order to bill for the exam that was intended, while in other cases it will garner extra reimbursement. Either way, it must be specifically documented in order for coders to properly bill for the procedures. In this article we will review the financial reasons for providing good documentation, identify when 3D reconstruction is required and when it is an additional charge, and finally understand the documentation requirements that will provide the maximum reimbursement in these various circumstances.

The American College of Radiology (ACR), Radiology Business Management Association (RBMA), and other similar provider advocacy organizations are busy analyzing and preparing responses to the Medicare Physician Fee Schedule (MPFS) Proposed Rule issued by the Centers for Medicare and Medicaid Services (CMS) recently.  According to the RBMA Washington Insider of July 14^th, “CMS estimates that if the provisions within the proposed rule are finalized, the overall impact of the MPFS proposed changes to radiology to be 0%, while interventional radiology would see an aggregate increase of 1%, radiation oncology a decrease of 3%, nuclear medicine a change of 0%, radiation therapy centers a decrease of 9%, and Independent Diagnostic Testing Facilities (IDTFs) a 1% increase.” 

Participation in Medicare’s PQRS program is important to radiologists in order for them to maintain full reimbursement under the Medicare fee schedule, and to perhaps earn a higher level of payment in future years.  Radiologists providing services in Independent Diagnostic Testing Facilities (IDTFs) will not be able to participate in PQRS, according to a ruling described in the June 16, 2015 issue of the RBMA Washington Insider.  This most recent guideline issued by the Centers for Medicare and Medicaid Services (CMS) clarifies past guidance by stating, “After further review, CMS is announcing that EPs [eligible professionals] who provide services under an IDTF or an independent lab (IL) (and on behalf of services provided by that IDTF or IL) are not able to participate in PQRS.  Therefore EPs who provide services [billed] under an IDTF or IL will not receive the 2015-2018 PQRS payment adjustments for services associated with the IDTF or IL”.  This reverses CMS guidance issued as recently as March, 2015.

A report issued by the Office of the Inspector General (OIG) on May 6, 2015 found that Medicare overpaid physicians approximately $33.4 million for services performed in facility locations that were incorrectly coded as performed in non-facility locations, such as ambulatory surgery centers and hospital outpatient departments.  The physicians identified in the audit will have to reimburse Medicare for the overpayments. 

Reimbursement rates for both Breast Ultrasound and Digital Breast Tomosynthesis (DBT) received a boost from the Centers for Medicare and Medicaid Services (CMS) this year.  Medicare adopted new CPT¹ coding that provides enhanced reimbursement for ultrasound services, and coverage was newly approved for DBT as an add-on to screening and diagnostic mammography examinations.  These changes were described in our article, The Impact of Coding Changes on Radiology Practices in 2015.  In order to fully realize the benefit of these new billing opportunities, proper documentation is required within radiology practices.

Buried in the 2014 legislation that delayed the Sustainable Growth Rate for a year was a provision that will penalize radiology groups that have not upgraded their CT equipment to the latest standards.  As described in the April 28, 2015 edition of Radiology Business,  “Beginning in January 2016, any exam acquired with a CT system that does not meet the XR-29- 2013 standard, also known as MITA Smart Dose, will be hit with a 5% penalty.  In 2017, that penalty jumps to 15%.  XR-29-2013 was published by the National Electrical Manufacturers Association’s Medical Imaging & Technology Alliance (MITA) in 2013, and is considered the industry standard for CT technology.”

Congress has enacted the “Medicare Access and CHIP Reauthorization Act of 2015” (MACRA), which makes sweeping changes to the Medicare payment system.  Initially conceived to put an end to the perennial struggle with the Sustainable Growth Rate (SGR) methodology, MACRA replaces the SGR with a valuation system that will minimally increment Medicare fees in the near term but which will eventually tie physicians’ fees to the quality measures they report. 

Will you have to be ready to use ICD-10 coding by October 1, 2015?  The answer is: "perhaps".  Current law says that this will be the earliest date for its implementation.  CMS, the Centers for Medicare and Medicaid Services, has stated that there will be no further extensions.  And, at the time of this writing, there is no indication that an ICD-10 extension will be included as part of legislation that would also extend the current Medicare fee schedule beyond its planned March 31^st expiration, but this could change as negotiations continue in Washington this week. 

As we have reported in a previous article, there are many good reasons to prepare for ICD-10 even if the Medicare program never requires it to be used!  The key to readiness is to improve clinical documentation so that the coding and billing team can do the best job possible to maximize your practice reimbursement, and this approach will also help improve your billing immediately.