Radiology Coding Alert

Our experts clear up your myelogram and supervision uncertainty

If you code for an independent diagnostic testing facility (IDTF), you know you have special hoops to jump through on the way to reimbursement. Find out what your IDTF needs to do to get paid.
 
Problem: I'm uncertain about the regulations for IDTFs. For example, can an IDTF expect reimbursement from Medicare for a lumbosacral myelogram?
 
Answer: Maybe. Consider the following rules to learn whether your check is in the mail.

1. Make sure you're coding for a diagnostic test
 
Medicare gives the code for a lumbosacral myelogram (CPT 72265 , Myelography, lumbosacral, radiological supervision and interpretation) a 9 in the "Supervision for Diagnostic Test" column of its National Physician Fee Schedule Relative Value File. This 9 means "concept does not apply." But, if you look at the column for 72265-TC (Technical component), the code is 3, personal supervision. Level 3 means the "procedure must be performed under the personal supervision of a physician" in the room during the procedure.
 
"The basic rule is that CMS instructs carriers to pay only for diagnostic tests," says Thomas W. Greeson, JD, an expert in radiology law with Reed Smith LLP in Falls Church, Va. This means "those tests that have a level of supervision assigned by CMS and [that are] identified in the Medicare Physician Fee Schedule list of diagnostic tests, updated annually." So if your IDTF followed that rule, you're one step closer to Medicare reimbursement.
 
You can find the 2005 level of supervision for diagnostic tests at www.cms.hhs.gov/providers/pufdownload/rvudown.asp.

2. Confirm that the test is on your list of Medicare-approved procedures
 
"When an IDTF applies for licensure, the facility provides a list of all the procedures that could be performed. If myelograms were not on the initial application and the facility wants to begin doing them, they can't," says Greg Schnitzer, RN, CPC, CPC-H, CCS-P, manager, coding, compliance and quality assurance at CodeRyte Inc. in Bethesda, Md.
 
If they want Medicare to pay, the IDTF needs to apply for a new license, Schnitzer says. There is more information on this available online at www.hgsa.com/professionals/bguides/idtf-m.html.
 
If you want to see the types of tests you can include, there is a list of acceptable IDTF procedures available at www.hgsa.com/professionals/pdf/mr0900.pdf, Schnitzer says. You'll find acceptable spine and pelvis codes, including myelograms, on page 30.
 
Alternative: The IDTF may perform procedures not on the list, Schnitzer says, but they won't be reimbursed for it by Medicare. He suggests checking with private payers to see if they'll pay.

3. Decide which codes to report

Depending on the circumstances, an IDTF may bill for the global myelogram, code 72265, or just the technical component, 72265-TC, Greeson says.
 
Example: Georgia Medicare instructs IDTFs to code based on the structure of the IDTF. If the IDTF employs the interpreting physicians (whether the physician provides purchased interpretations or reassigns his benefits to the IDTF), the IDTF reports global 72265. If the IDTF performs the technical component and then sends the data to another physician for interpretation, the IDTF should report 72265-TC. Find this information online at www.gamedicare.com/newspubs/apr03/28.htm.
 
Snag: Compensation for the surgical service is not included, regardless of whether you code for the technical component or the global service for this radiological supervision and interpretation. Generally, surgery code 62284 (Injection procedure for myelography and/or computed tomography, spinal [other than C1-C2 and posterior fossa]) goes hand in hand with most myelograms to indicate the injection along with the supervision and interpretation. But Medicare won't automatically pay IDTFs for surgical codes because they are not diagnostic tests.
 
Try this: According to Georgia Medicare, IDTFs may code certain items or services needed to perform particular, approved diagnostic tests if the carrier agreed to reimburse that IDTF for those items and services at the same time the carrier agreed to reimburse for the tests. "The IDTF must identify all such items/services that it intends to bill in conjunction with specific tests. Each IDTF will have a specific and unique list of HCPCS codes for which it can be paid by the Carrier, and it is the responsibility of the IDTF to obtain specific Carrier approval to bill each HCPCS code that it intends to bill." (See www.gamedicare.com/newspubs/apr03/IDTFDiagTests.pdf for more information.)
 
4. Don't forget the extra details

If the patient has a medically necessary computed tomography (CT) ordered to be performed after the myelogram, you should also code for this, and because contrast is used within the thecal space for the myelogram, code CT with contrast. In this case, report 72132 (Computed tomography, lumbar spine; with contrast material). Code 72132-TC has a supervision level of 2, meaning the physician needs to be in the office suite and within earshot. If the physician also provides the interpretation of the images and the supervision, this CT service may also be billed as a global service, rather than appending -TC.
 
Because you're billing for the technical or global, you also report the contrast material with A4644-A4646 or other appropriate contrast code(s), the surgical tray with A4550, and the pharmaceuticals injected with the appropriate HCPCS code. Though Medicare typically doesn't reimburse for supplies, considering them to be bundled into the procedure, other insurers may provide separate payment.
 
Tip: If you don't qualify to bill Medicare and you are going to try to have the patient pay for the test, you must notify the patient in advance, and you will need to have him sign an advance beneficiary notice (ABN) to indicate to Medicare that he knew he would have to pay,  Schnitzer says.
 
Editor's note: Send your concerns about coding for IDTFs to deborahd@eliresearch.com and we may choose your submission for a future issue.