Pulmonology Coding Alert

Using modifier CT? Brace yourself for a 15 percent cut in 2017.

Have you been facing denials of your advanced imaging procedures lately? Well, you may not be the only one. In fact, according to the Centers for Medicare & Medicaid Services (CMS), about 12.4 percent of 2015 claims for these services were inappropriate. Know what it takes to successfully claim your revenue, starting from proper documentation, pacifying Medicare review contractor queries, and using modifier CT.

The issue: The major cause of improper payment for these services was insufficient documentation, CMS says in a Medicare Learning Network compliance tip sheet ICN907793. Reporting for the Comprehensive Error Rate Testing (CERT) program found that up to 91.7 percent of 2015 claims lacked requisite documentation. In fact, in over half of the claims, even the provider’s orders were missing, according to CMS.

If you too have been a little off guard, it’s time to get back on track.

Key: “It is important for pulmonologists to know the proper documentation for these claims to avoid any patient burdens for studies that they order,” says Carol Pohlig, BSN, RN, CPC, ACS,  senior coding and education specialist at the Hospital of the University of Pennsylvania.

“We get a lot of prior authorizations that are denied for medical necessity, when it really is medically necessary, they just need to dig for the answers,” says Lisa Center, CPC, Physician Practice Manager, Via Christi Hospital Pittsburg, Inc. Pittsburg, KS.

Follow the Requisite Modus Operandi

According to Medicare’s “National Coverage Determination (NCD) Manual,” NCD 220.1, CT scans must be medically appropriate considering the patient’s symptoms and preliminary diagnosis.

“Most of the time we are dealing with cancer of the lung and they really need these tests, so we try very hard to get them approved,” Center says. “Otherwise, it is the patient’s responsibility, and they end up cancelling the test because they don’t want to pay for it themselves.”

Here is what you can do to stay compliant with the claim requirements and prevent denials according to the MLN article ICN907793 (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CTScans-ICN907793-.pdf)

• First things first, ensure that there is an order for performing a CT scan, and the provider has signed it legibly. Keep a copy of the order.
• The medical record must have a documentation that the provider performed a CT scan.
• Secure a copy of the report of the CT scan as well.

How to Pacify Medicare Review Contractor Queries

If you do happen to receive a documentation request from a Medicare review contractor, here’s what CMS article advises you to send:

1. The provider’s order: If you don’t have this on hand, contact your provider right away and request them to send you a copy of the order, or any other medical record prior from the day of CT scan that demonstrates the provider’s directive of getting a CT scan done for the patient.
2. Medical Necessity: Enclose appropriate medical records to justify the clinical rationale why the patient requires the scan “including the results of any prior testing with rationale for advanced testing,” Pohlig says.
3. CT scan procedure documentation: A copy of the entries your provider made in the patient’s record during the CT scan. This may seem a little trivial, but you must send as much information to strengthen your claim, and Medicare does ask for this as well.
4. The radiologist’s interpretation and report: Remember to compile the CT scan report, legibly signed by the interpreting provider.

Use Modifier “CT” Where Appropriate

According to MLN Matters^® Article MM9250 (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/ MM9250.pdf), if the CT equipment does not meet the NEMA standards, you will have to include modifier CT (Computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association [NEMA] XR-29-2013 standard), which will result in a 5 percent payment reduction in 2016, and a fifteen percent payment reduction in 2017. So make sure the billing staff is aware of the standards and payment reductions.

MLN Matters® Article MM9486 advises that effective January 1, 2016, Medicare requires that hospitals and suppliers use this modifier on claims for CT scans described by applicable HCPCS codes furnished on equipment that does not meet the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013. Applicable pulmonology HCPCS codes include:

• 72125-72127 (Computed tomography, cervical spine…)
• 72128-72133 (Computed tomography, thoracic spine…)
• 72131-72133 (Computed tomography, lumbar spine…)
• 72191-72194 (Computed tomography, pelvis…)
• 71250-71270 (Computed tomography, thorax…)
• 75571-75573 (Computed tomography, heart…)
• (and any succeeding codes)

The road ahead: “Ensure that your patients’ services are justified by providing the proper documentation and rationale for the studies that your pulmonologist orders,” Pohlig says. “Patients do not have CT scans performed as their first-line of testing. Ensure that you meet the coverage criteria of your patients’ insurer, prior to electing for CT studies.”

On a similar note, providers need to keep up to date and ensure they are in compliance with the documentation requirements, says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president, Healthcare Resource Management, Inc. Spring Lake, NJ.