Radiology Coding Alert

Standing orders for 3-D reconstruction can also get you into trouble 

If you're coding 76375 with every computed tomography as a matter of protocol or standard of care, stop - you must have an order from the treating physician to prove the service is medically necessary for each patient.
 
The Office of Inspector General recently accused a Florida radiology group of fraud because the group could not produce written orders to prove medical necessity for scores of tests. One major issue was the absence of orders for 76375 (Coronal, sagittal, multiplanar, oblique, 3-dimensional and/or holographic reconstruction of computed tomography, magnetic resonance imaging, or other tomographic modality).  
 
Performing 3-D reconstruction is popular among radiologists as a way to avoid malpractice suits or as part of a standard protocol or specific diagnosis, says Cheryl Schad, BA, CPCM, CPC, owner of Schad Medical Management, a medical reimbursement consulting firm in New Jersey. "What they don't remember is that no insurance carrier is interested in paying for anything that isn't medically necessary." 
 
Because of the audit, the American College of Radiology is working with the Centers for Medicare &  Medicaid Services to investigate whether the 3-D reconstruction should be exempt from the test ordering rules as a test design exception. Until official word comes down, you're safest if you have a treating physician's order before you code 76375. "Now that the OIG is aware that these things go on, it's going to be looking at other radiology departments," Schad says. "There's no doubt about it."   
 
More information on ordering diagnostic tests is in Medicare Transmittal 1787 at www.cms.hhs.gov/manuals/pm_trans/R1787B3.pdf.