HAP Radiology Billing and Coding Blog

As with any medical procedure, the performance of abdominal ultrasound examinations is defined by specific practice parameters. Likewise, the documentation of those exams must also comply with certain criteria in order for the practice to realize full reimbursement for them. The accepted guideline¹ for the performance of abdominal or retroperitoneal ultrasound exams indicates, “Depending on clinical indications, an examination may include the entirety of the abdomen and/or retroperitoneum, a single organ, or several organs.” Similarly, the documentation must contain an exact description of the procedure for proper billing.

Healthcare Administrative Partners continues our efforts to help radiology practices make a successful transition to ICD-10 with this article, the third in our series focusing on how radiologists can fine-tune their documentation to assure the best coding and uninterrupted reimbursement.  Our previous articles covered Documentation for Pain and Documentation for Fractures and our blog contains additional information to help radiology practices prepare for this major change.  

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.

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.

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.

The landscape of Medicare payment policy will be changing over the coming years as a result of actions taken in 2014 through the Medicare Physician Fee Schedule (MPFS) and the Protecting Access to Medicare Act (PAMA).  The MPFS for 2015 contained fewer changes to current payment policy than it did proposals deferred for future consideration.  The Protecting Access to Medicare Act of 2014 (PAMA) was initiated to avoid the significant Medicare payment reduction imposed by the Sustainable Growth Rate (SGR) provision in the Medicare law, but it also contained other provisions affecting payment under the Medicare program. 

The Centers for Medicare and Medicaid Services (CMS) announced that Medicare coverage for lung cancer screening using low-dose CT (LDCT) scans would become effective as of February 5, 2015.  However, according to the American College of Radiology (ACR), we are likely a few months away from publication of the details needed before radiology practices can begin submitting claims to Medicare for these scans.  They recommend that “physicians meeting the coverage criteria should hold all claims for low-dose CT lung cancer screening until further reimbursement instructions are released by CMS.”  The article “College Addresses Lung Cancer Screening Questions” appeared in the February 13^th edition of the ACR’s Advocacy in Action eNews. 

Good documentation is the key to optimal coding and reimbursement for radiology procedures.  By including all of the essential elements in the radiology report, physicians give their coders all of the information they need to get the billing done most efficiently.  But when the report lacks some required piece of data, the coders must contact the radiologist for clarification.  At best, this slows down the billing process but, at worst, it leads to under-coding and therefore lower payment than is possible for the procedure.

The stage is set for a new era of Medicare payment modification using data self-reported by physicians that measures the quality of their work.  The two programs already in place are the Physician Quality Reporting System (PQRS) and the Value-Based Payment Modifier (VM).  These two will work in concert to determine either a positive, neutral or negative payment adjustment to the basic Medicare fee schedule, generally two years following the reporting year.  Note that the rewards and penalties for these programs are cumulative; failure to meet the PQRS reporting requirements will invoke a penalty under both the PQRS and the VM programs.