the treasure hunt—keys to unlocking radiology reimbursement payment walt blackham, ms, rcc...
TRANSCRIPT
The Treasure Hunt—Keys to Unlocking Radiology Reimbursement PAYMENT
Walt Blackham, MS, RCCRadiology Business Management Association, RBMA
THE ROLE OF CODING
Communication between You, the healthcare provider) and the
PayerThe PatientThe insurance CompanySome other third party
Correct Coding: Why Bother?
THE ROLE OF CODING
Proper coding is the initial (and most important) step in the process of obtaining correct payment for the services you provide.
Proper coding is the first building block for Corporate Compliance
THE ROLE OF CODING
Coding is a unique language
THE ROLE OF CODING
CPT 4Current Procedural Terminology AMA code set for physician services Describes what you did Under HIPPA CPT is the uniform
coding setCPT 5 in development
THE ROLE OF CODING
CPT 5 digit alphanumeric code set
• Category 1 from 00100-99602• Category 3 - 0016T-0170T
2 digit modifiers • “…indicate that a service or procedure that has
been performed has been altered by some specific circumstance but not changed in its definition or code.”
THE ROLE OF CODING
CPT Rules of procedure coding
“Select the name of the procedure or service that accurately identifies the service performed.”
“Do not select a CPT code that merely approximates ……”
THE ROLE OF CODING
CPT Rules of procedure coding
“If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code. “
New CPT Codes
• Application from the AMA with clinical vignettes
• Usually handled thru the medical professional societies
• CPT Advisory Committee • CPT Editorial Panel • AMA/Specialty RVS Update Committee (RUC)
Level II HCPCS
Medicare alphanumeric codes for; Procedures e.g. digital mammography Non-Ionic Contrast Radiopharmaceuticals Other drugs and codeable supplies
THE ROLE OF CODING
ICD-9-CM Diagnosis codes describe why you
did the particular CPT code
THE ROLE OF CODING
ICD-9-CM3 to 5 digit alphanumeric codes
001.0 through 999.9V01.0 through V86.1
THE ROLE OF CODING
For proper ICD-9 Coding code:
A. Highest Level of Specificity
Use 4th and 5th digits when available
B. Highest Level of Certainty
Code positive results if relevant to the
encounter
THE ROLE OF CODING
As specified in §4317(b) of the Balanced Budget Act (BBA), referring physicians are required to provide diagnostic information to the testing entity at the time the test is ordered.
THE ROLE OF CODING
PAIN!!!!!!The Central Office for ICD-9-CM has sent a
letter in stating that The Cooperating Parties of ICD-9-CM (AHA, AHIMA, CMS, NCHS) “..agreed that since the x-ray was specific to a site (in this case, the neck), the more specific code for “neck pain” or 7231, Cervicalgia, may be assigned as the reason for the x-ray.”
THE ROLE OF CODING
According to the *Official Guidelines for Coding and Reporting* (Section IV), in the outpatient setting, diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ or ‘working diagnosis’ are not coded. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”
THE ROLE OF CODING
“These terms
[‘consistent with,’ ‘compatible with,’ ‘indicative of,’ ‘suggestive of,’ and ‘comparable with’]
fit the definition of a probable or suspected condition”
THE ROLE OF CODING
“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.”
DOCUMENTATION MODEL
Model based on ACR Practice Guideline for Communication of Diagnostic Imaging FindingsDemographics
• Patient Identifiers, name, ID #• Facility Name / location• Referring Physician name• Date of Exam• Etc.
DOCUMENTATION MODEL
Name or type of ExaminationUse terminology as listed in CPTPlain films - specify number of viewsCT & MR - without, with or with and without contrast
SPECIFY WHICH FOR EACH EXAMINATIONNuclear Medicine - CPT name not radiopharmaceutical name
Note: If a combination of services are performed in the same session, each should be separately dictated and documented in the written report
DOCUMENTATION MODEL
Time of Exam Where Appropriate Multiple portable chests on the same
day
DOCUMENTATION MODEL
Reason for the Exam
Relevant Clinical IndicatorCannot use rule-out or probable diagnosis
for billingFor billing must have signs and
symptoms, for example, pain or injury if exam is negative
However, The MORE clinically information the better.
DOCUMENTATION MODEL
Body of ReportImpression or Conclusion
• Except if report is very briefRendering radiologist’s name
The Radiology Report
If you can’t read it, you can’t code it.
Questions?
Walter C. Blackham, MS, RCC
President and CEO
Specialty Medical Services, Inc.
221 West 8th Street
Lorain, OH 44052-1817
440.245.8010 Ext. 10