Radiology Coding Alert

Want to avoid OIG scrutiny in 2004?  Watch your IDTF claims

You've assigned the right code to an MRI, confirmed that the radiologist's interpretation is in the file, and clipped the ordering physician's MRI order to the patient's chart. Another pristine chart guaranteed to bring your IDTF quick payment, right? Not so fast. If a physician who is excluded from the Medicare program ordered the MRI in the first place, Medicare and other federal payers won't reimburse you for your work.
 
Although this has been the case for years under the U.S. Office of Inspector General (OIG) Exclusion Program, a recent OIG review has launched it into the spotlight and made it a major concern for radiologists. As an investigative focus area that the OIG identified in its recently released 2004 Work Plan, independent diagnostic testing facilities (IDTFs) and outpatient hospital departments will essentially have to "credential" every physician who orders Radiology services.
 
1. Did Excluded Physicians Order Radiology Testing? You Won't Get Paid. The Work Plan indicates that physicians excluded from federal healthcare programs are precluded from ordering and performing services for Medicare beneficiaries. A recent OIG review, however, revealed that excluded physicians ordered "a significant number of services."
 
Most IDTFs simply can't afford to have scores of diagnostic testing services denied just because an ordering physician was excluded from the Medicare program - and this is particularly frustrating when physicians don't self-disclose that they are excluded.
 
So how can you credential your facility's ordering physicians? The OIG maintains a database of excluded physicians. You can either download the entire database or search it using physician names or business names. Visit http://oig.hhs.gov/fraud/exclusions.html to access the database. Remember that this database is constantly changing, and you should make certain that you have current exclusion information.

2. IDTFs Must Buckle Down. The OIG will also investigate the medical necessity of services performed in IDTFs. On the docket is a review of whether such services were medically necessary, whether facilities had prior approval to provide such services, whether physicians appropriately supervised the services, and whether personnel who provided the services were properly credentialed.

3. Double-Check Orders for Diagnostic Tests in the ED. You need to be certain you have sufficient documentation before coding diagnostic tests your radiologist performs in the emergency department (ED).
 
The OIG intends to assess whether diagnostic tests performed in hospital emergency rooms are medically necessary and interpreted appropriately for the patient's condition. Because the Emergency Medical Treatment and Active Labor Act (EMTALA) requires that emergency room patients be screened and stabilized, radiologists are often called to test the patient as part of the "screening." If you perform diagnostic testing such as x-ray, ultrasound, angiography, myelography or other tests in the ED, medical-necessity documentation for testing will be critical in the coming year, says Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Dallas, Ga.
 
Most carriers require written reports describing the radiologists' findings in EDs. Illinois Medicare's local medical review policy (LMRP), for example, states, "A professional-component billing based on a review of an x-ray or an EKG procedure, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment since the review is already included in the ED physician's E/M payment."
 
For instance, the LMRP says, "a notation in the medical record saying 'fx tibia' or 'EKG normal' would not suffice as a separately payable interpretation." A reimbursable interpretation should include the physician's findings, relevant clinical issues and comparative data when available.

4. Use Modifier -59 With Caution. The new Work Plan may cause trouble for those practices that submit many claims with modifier -59 (Distinct procedural service). The OIG intends to "determine whether claims were paid appropriately when modifiers were used to bypass National Correct Coding Initiative (NCCI) edits," according to the report. Although several modifiers - including -78 (Return to the operating room for a related procedure during the postoperative period) and -79 (Unrelated procedure or service by the same physician during the postoperative period) - can separate services bundled by the NCCI edits, radiologists usually use modifier -59.
 
"Physicians should be aware that when they append modifier -59, they are representing the fact that they have documentation on file that supports using it," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center. "Therefore, you should always be prepared to submit additional documentation that demonstrates that your procedures were separate and distinct from one another." If your documentation won't prove the separate nature of the bundled services, Jandroep says, don't append modifier -59.

5. Count Five Fractions When Reporting 77427. And don't think the OIG will let your radiation oncology services off easy. The OIG will also zoom in on radiation oncology services, focusing on the physician weekly treatment management code 77427 (Radiation treatment management, five treatments). The Work Plan states, "Medicare regulations require that the professional component of radiation therapy management services be reimbursed to physicians as one billable unit of service for every five sessions of treatment." A prior review of one Medicare carrier, however, revealed "a high percentage of overpayments to physicians for radiation therapy management services."
 
Although the OIG identifies the weekly management code, "It is safe to assume that all radiation services will be reviewed," Parman says.
 
The most common error when reporting 77427 is that coders think it refers to a week's worth of treatment, no matter how many fractions they administer. "Weekly management is reported for every five fractions (or sessions) delivered, regardless of the time interval between fractions," says Deborah I. Churchill, RTT, president of Churchill Consulting Inc., a Killingworth, Conn., consulting firm that offers audits, seminars and electronic coding applications. "I often find that physicians report on a 'weekly basis' - Monday through Friday - without consideration of the five-fraction rule."
 
And, Churchill says, the physician must include a progress note in the patient's medical record, demonstrating that the patient was seen during each five-fraction period reported. "Oftentimes, the physician will see the patient twice during one five-fraction period, but doesn't see the patient during the next five-fraction period, so the second week of management is not reportable."
 
She advises practices against programming their computers to "auto-post" their weekly management every time five fractions are entered on a particular patient's chart. "If no one checks the medical record to ensure that the patient was actually seen during the period posted, this could be construed as fraud, as they are reporting services that have not been performed and therefore aren't billable," Churchill says.
 
The OIG Work Plan includes information about all of its investigative focus areas for 2004. You can access the full 90-page document by visiting the OIG's Web site at www.oig.hhs.gov/publications/docs/workplan/2004/WorkPlan2004.pdf.