Pulmonology Coding Alert

Help cut denials in half with this easy-to-implement advice.

Diagnosing patients with complicated lung conditions can be challenging, but one thing that helps make diagnoses easier is the use of imaging. But as much as imaging helps physicians pinpoint patients' conditions, these tests can confound coders, who experience denials for CT and other imaging studies. Check out the following three tips to help stem denials when your pulmonologist orders imaging services such as computed tomography (CT) scans.

Tip 1: Nail Down Documentation

The most important thing to get right in terms of imaging payment is to maintain the right documentation. The patient won't even be able to get the scans and tests they need if the order is missing the appropriate information, and insurers will deny pre-authorizations without the right diagnosis codes and other documentation required for medical necessity.

According to Medicare's "National Coverage Determination (NCD) Manual," CT scans must be medically appropriate considering the patient's symptoms and preliminary diagnosis. To stay compliant with these rules, you should consider using some tips from the Medicare Learning Network document, "Provider Compliance Tips for CT Scans," which include the following:

• 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 and keep it on file.

In addition to documenting the order appropriately, the medical record should indicate the clear reasons for the imaging studies. For example, "Mr. Jones, who is 69 years old, was diagnosed with emphysema when he lived in New Jersey three years ago; he is not on therapeutic oxygen but does use an inhaler as needed. He has not seen a doctor since moving to Florida last year. He reports difficulty walking more than six feet and must sit down frequently when exerting himself in any way, including dressing, bathing, and getting out of bed. The patient is gasping for air while sitting and his breaths are shallow, slow, and labored. I am referring him for a CT scan to determine the severity of his condition and evaluate for lesions."

Tip 2: Remember to Sign Those Orders

One detail that's easy to comply with – but can also be easy to forget -- is the signature on the imaging order.

Background:  CMS requires physicians to personally sign orders, but practices are starting to see an uptick in denials related to such technicalities. And as Medicare Administrative Contractors (MACs) continue to earmark documentation faux pas in their Targeted Probe and Educate (TPE) reviews, it's essential for practices to work together to eradicate instances where the authoring physician did not sign the order.

Such situations can arise pretty easily, especially when colleagues verbally discuss tests and forget to cross the t's and dot the i's.

Reminder: "For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author," the Medicare Program Integrity Manual says. "The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable."

CMS clearly outlines what constitutes a "valid signature." According to the agency's guidance, you should consider these three questions before you send over your Medicare claims:

• Are the ordered and/or performed services properly authenticated by the ordering provider?
• Are the signatures handwritten or electronic in nature? (Note that stamped signatures are acceptable in cases where the Medicare provider has a documented disability that is known to the MAC and impedes a handwritten or electronic signature).
• Is the signature legible?

If the physicians in your group don't meet these criteria, schedule an educational session where you discuss what the practitioners must do to meet the requirements.

3. Respond Expediently to Medicare Review Contractor Queries

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

• The provider's order: If you don't have this on hand, contact your provider right away and request 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.
• 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.
• 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.
• The radiologist's interpretation and report: Remember to compile the CT scan report, legibly signed by the interpreting provider.

The Bottom Line: Ensuring that your orders are airtight before you submit your imaging claims will save time fighting denials down the road.