Radiology Coding Alert

CMS is adding some sizzle to your summer with three exciting Physician fee schedule changes. Sacroplasty, renal tumor ablation, and stereoscopic x-ray guidance for radiation therapy all have news you need to know now  or you could risk leaving hundreds or even thousands of dollars on the table.

Effective date: CMS transmittal 1748 reveals the changes (www.cms.hhs.gov/transmittals/downloads/R1748CP.pdf). The implementation date, when carriers must be prepared to execute the changes, is July 6. But the effective date is Jan. 1, meaning that the changes actually apply to services performed as far back as Jan. 1.

The AMA announced new spine-related Category III codes, implemented July 1. CMS added them to the physician fee schedule with a "C" procedure status, meaning that individual carriers will establish payment amounts. Because they are carrier-priced, the national fee schedule does not include relative value units for these codes.

"It will be interesting to see how carriers price the sacroplasty codes, since many were not paying for this service with the unlisted code 22899 (Unlisted procedure, spine)," says Mary Rice, a Memphis, Tenn.-based coding and practice management consultant.

The new codes and instructional notes are as follows:

• 0200T -- Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device (if utilized), one or more needles

• 0201T -- Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device (if utilized), two or more needles

(For radiological supervision and interpretation, see 72291, 72292) (If bone biopsy is performed, see 20220, 20225).

RS&I: Be sure you catch the parenthetical note indicating that 72291 (Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance) and 72292 (... under CT guidance) are appropriate for reporting radiological supervision and interpretation.

Some practices choose to advance the needles under CT guidance (72292) and inject cement under fluoro (72291). Correct Coding Initiative edits currently consider these codes mutually exclusive, so you should report only one. The CT guidance code has a slightly higher value.

Bone biopsy: The notes also instruct that you may report bone biopsy separately using 20220 (Biopsy, bone, trocar, or needle; superficial [e.g., ilium, sternum, spinous process, ribs]) or 20225 (... deep [e.g.,vertebral body, femur]).

Requirement: CPT instructions are clear on Category III code use -- report them instead of an unlistedprocedure Category I code whenever available. Because coverage and reimbursement remains a payer decision, you should follow the same process with reporting Category III codes as you do with unlisted-procedure Category I codes.

With Category III codes, you're not only following the instructions provided by CPT, but you're providing data that could help support a Category I code in the future.

The list of new Category III codes is on the AMAWeb site at www.ama-assn.org/ama1/pub/upload/mm/362/cptcat3codes12-29-08.pdf.

In addition to listing new codes, the July fee schedule update also changed the bilateral status for existing code 50593 (Ablation, renal tumor[s], unilateral, percutaneous, cryotherapy) -- a correction that boosts the official bilateral rate 50 percent.

Prior to the update, CMS listed this code with bilateral indicator "0." A "0" indicator means that the payment adjustment for bilateral procedures does not apply, says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. So if you report a "0" procedure with modifier 50 (Bilateral procedure), or with modifiers RT (Right side) and LT (Left side), Medicare reimburses you for whichever is lower:

• the actual charge for both sides, or

• 100 percent of a single code's fee schedule amount.

The July update announces a change to bilateral indicator "1," retroactive to Jan. 1.

The "1" indicator means that the 150 percent payment adjustment for bilateral procedures applies. So if you report the code with modifier 50 or report it twice in any way, CMS bases payment on the lower of:

• the total actual charge for both sides, or • 150 percent of a single code's fee schedule amount.

Note that the 50593 descriptor states the code is for a unilateral procedure, so the original "0" bilateral indicator was an error.

Payoff: The national rate for 50593 is roughly $478 in the facility setting, so the change to the 150 percent reimbursement amount raises the national bilateral rate by almost $240. The non-facility price is roughly $4,610, so the bilateral indicator change boosts the national bilateral rate by roughly $2,305.

Resource: The "National Physician Fee Schedule Relative Value File Calendar Year 2009,"available with the fee schedule files on the CMS Web site, lists the bilateral indicator definitions.

CMS also announced changes to the technical 77421 (Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy) physician supervision requirement.

Old way: Before the switch, the physician supervision indicators for 77421's technical component (TC) was personal supervision (03):

• (03) Personal supervision: "Personal supervision does not mean the doctor has to perform the procedure; he just has to be there in person supervising the procedure," explains Erin Goodwin, CPC, CMC, reimbursement and coding professional with South Carolina Oncology Associates.

In other words, the physician must be in the room for services requiring personal supervision.

New way: The July update changes the TC supervision requirements to direct supervision (02):

• (02) Direct supervision: When your physician is present and immediately available to furnish direction and assistance throughout the procedure, consider it "direct supervision." Remember, however, that "direct supervision" doesn't mean your physician must be present in the room during the procedure -- just that he's in the vicinity and immediately available in person if needed.

By changing the technical component requirement from personal to direct supervision, CMS has changed from requiring the physician's presence in the room to requiring the physician to be immediately available, which is helpful for those coding the technical side.

ASTRO and other societies advocated this change, contending direct supervision was more appropriate than personal supervision for 77421.

Personal supervision "limits other things the doctor can be doing in the clinic," Goodwin says. The physician "could be doing a consult, working on planning, etc., instead of personally supervising IGRT [image guided radiation therapy]," she says.

Remember: Your documentation needs to support the supervision level for the code you choose, or CMS will demand a refund during audit, Goodwin warns.