Radiology Coding Alert

A central focus of Medicares audit campaign in the upcoming year will be compliance within solo and small group practices, according to Kimberly Brandt, senior counsel with the Office of the Inspector Generals (OIG) Civil Recoveries Branch. She says OIG is drafting a model compliance plan that will emphasize 12 areas that have been identified as particularly problematic with small practice groupsa category that aptly describes the majority of radiology practices:

1. Kickbacks
2. Routine waiver of co-payments and deductibles
3. Billing for services not rendered
4. Upcoding
5. Unbundling
6. Double-billing
7. Billing for physician services rendered by
nonphysicians
8. Medical necessity
9. Misrepresenting diagnosis to justify services
10. Completing certificates of medical necessity for patients not personally or professionally known by the physician
11. Billing Medicare or Medicaid for investigational
research, medications, and/or procedures without proper authorizations
12. Billing for a noncovered service as if covered

Compliance Plan Saves Moneyand Headaches

The most effective response to Medicares focus on small practices is to develop and follow an internal compliance plan, advises Thomas A. Kent, CMM, president of Kent Medical Management in Baltimore, Md., who has worked with national medical centers on compliance.

Its not difficult, but it can save any radiology group a lot of headaches, he points out. A compliance plan can be as simple as a short booklet that describes the billing process in your office. Components that should be addressed and clearly outlined, Kent says, include:

Which individuals handle the billing process;

What responsibility each assumes in the process;

Who reviews claims that have been denied by Medicare;

What system is in place to track denials and identify any patterns that indicate errors;

How denial patterns, errors or problems are communicated to office and medical staff; and

What system is in place to correct problems and ensure the situation has been resolved.

It is my firm belief that most radiologistsand the majority of other physiciansare very honest, Kent says. Many of the compliance problems arent conscious attempts to defraud the government. They result when someone is documenting or reporting a service incorrectly and isnt aware of it. Unfortunately when it comes to fraud, the government does not have to prove intent. They only have to show a pattern of noncompliance.

A well-thought-out compliance plan, he adds, indicates that a radiology practice has made a good-faith effort to comply with national Medicare and local carrier requirements. If you have a plan in place and can demonstrate that you abide by it, it will help you minimize any penalties in case Medicare conducts an audit and finds problems.

Another effective strategy, Kent says, is to emphasize educational programs that keep medical and office staff abreast of coding and compliance issues. Obviously, everyone on the billing staff needs to have continuing education about radiology coding. It is an ever-changing and complicated field.

But the physicians also need to make sure they understand these issues as well, he adds. They need to ensure that their documentation and dictation clearly support the services provided, for instance. And, if a pattern of Medicare denials is discovered through the practices compliance plan, the radiologist needs to be informed and involved in solving the problem.

Communication needs to extend beyond the radiologists office walls, as well. Sometimes the radiologist will need to educate referring physicians, too, Kent points out. You want to make sure you are receiving good diagnosis codes, and that the referring physician includes relevant signs and symptoms.

Inadvertent Coding Errors May Constitute Fraud

Kent says that because radiology coding is so complex, coders must be aware of areas where inadvertent errors may be construed as fraud.

Example: A radiologist may conduct mammograms on patients who have been diagnosed with fibrocystic breast disease (610.1). Because of the underlying disease, the radiology coder may feel justified assigning the CPT diagnostic code 76090 (mammograph;, unilateral) or 76091 (bilateral). Some local carriers have ruled that, unless a patient with previously diagnosed fibrocystic breast disease presents with suspicious changes, signs or symptoms, the screening mammography code (76092, screening mammography, bilateral [two view film study of each breast]) would be assigned.

In this case, if an audit were conducted and the diagnostic mammography code had regularly been reported, Kent says, this practice would be guilty of fraud. And that would be expensive. The local Medicare carrier may assume that this had been going for a while and may ask to be reimbursed for its overpayments for a number of years. In addition, the practice would be asked to pay interest and a substantial penalty. That could easily add up to hundreds of thousands of dollars.

Prepayment Audits May Raise Red Flags

Radiologists inadvertently may invite compliance scrutiny when Medicare conducts a prepayment audit. Sometimes, after a radiology practice submits a claim, Medicare will want to check it out before they pay and ask for all documentation, Kent explains. If its a small claim, the physician may decide its not worth the time or trouble to gather all the paperwork, and let the claim go. This may be a good business decisionbut its a terrible compliance decision.

When there is no response to their request, Medicare may interpret this as the physician lacking sufficient documentationwhich spells trouble. Radiologists need to view these situations strategically and understand how Medicare might construe their response.

Why Is Medicare Focusing on Small Practices?

Many radiology coders are questioning why Medicare has targeted practices like theirs. Some say that Medicare is borrowing this strategy from the Internal Revenue Service (IRS), Kent says. The IRS believed that the threat of a comprehensive audit kept the majority of taxpayers honest. Likewise, Medicare may believe the threat of an audit may improve compliance. Certainly Medicare, through the OIG, is indicating its intent to carry out prosecution for fraud to radiology practices of any size.

He adds that this audit focus follows Medicares systematic audits of medical school billing, and does not replace its efforts directed at larger institutions. In addition, Kent notes that some states are beginning to audit Medicaid compliance as well, which could have a tremendous impact on radiology practices.