HAP Radiology Billing and Coding Blog

Imagine that your radiology practice realized a $750,000 in underpayments in two years. Now consider the impact such a shortfall would have on your practice’s ability to grow or even sustain itself. In this actual case, a payer was reimbursing 10 of the group’s physicians correctly while underpaying another 15 for the same procedures at the same time. This is a vivid lesson in the importance of continually monitoring third-party payments to ensure payers are reimbursing you at your contracted rates.

Radiology practices using teleradiology – servicing both hospitals and imaging centers – will have to consider whether they need to make any changes to their billing and reporting due to Medicare’s final Place of Service rules. CMS, the Centers for Medicare and Medicaid Services, has long been trying to establish rules for reporting the location of physician services. However, the rules have been delayed by questions and logistical problems that have been raised by those affected, primarily in the radiology community. Although many questions remain, CMS has issued what it considers to be its final set of rules, and they will become effective April 1, 2013. Practices should take a look at their service locations to see if they are operating in more than one payment locality and whether physicians are reading in locations other than where the patient was seen. If so, there is work to be done to prepare for the changes needed to submit radiology billing claims under the Medicare Physician Fee Schedule. 

Clinical documentation is the foundation of the health record, while the conversion of this narrative description into codes serves as the basis for reimbursement, quality reporting and other administrative and research activities. While documentation is often adequate from a clinical perspective, payer requirements, quality programs and government regulations often dictate specific requirements for reimbursement.

Even though Congress has averted the across-the-board SGR fee schedule cut (26.5%) for another year, radiologists will take another 3% cut this year. This, in addition to expanding the PC MPPR of 25% for CT, MRI and ultrasound imaging to include other members of the group practice, means that there is no good news for radiologists this year.

It seems like a simple premise: Identify the services provided, substantiate the reason, interpret your findings, bill the payer and receive compensation per your contract. However, charge capture in radiology is anything but simple, especially in a hospital. Considering the high volume of procedures performed, coupled with multiple departments, personnel and IT systems involved in the process, there’s plenty of opportunity for error.