Radiology Coding Alert

Modifier CT will generate a 15 percent cut in 2017.

Now is the time to assess how you are reporting for advanced imaging procedures. Inadequacies will bring higher cuts in 2017.

Advanced imaging like CT procedures are notorious for improper payments. Back in 2015, the ‘Medicare Fee-for-Service 2015 Improper Payments Report’ listed advanced imaging in the top 20 procedures for improper payments. According to the Centers for Medicare & Medicaid Services (CMS), about 12.4 percent of 2015 claims for these services were inappropriate. The trends in 2016 will soon unfurl as time goes by.

Key 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 about 50% of the claims, the provider’s orders were missing, contributing to the inadequate documentation.

Details: You can read more in the ‘Medicare Fee-for-Service 2015 Improper Payments Report’ at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/CERT-Reports-Items/Downloads/AppendicesMedicareFee-for-Service2015ImproperPaymentsReport.pdf.

Here is what you should do to meet the requirements for CT claims.

Establish Medical Necessity

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. “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.

“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)

Always be sure to have the following essentials:

• There should be 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 documentation that the provider performed a CT scan.
• Append a copy of the report of the CT scan.

Respond to Medicare Review Contractor Queries

If you do happen to receive a documentation request from a Medicare review contractor, here’s what the 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.
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 that you can 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 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…).

The road ahead:  Make sure you have all needed documentation and include the rationale for imaging. Ensure that you meet the coverage criteria of your patients’ insurer, prior to electing for CT studies.

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.