Radiology Coding Alert

On July 1, 2001, HCFA intends to implement revised Forms 855, the applications all healthcare providers and suppliers complete to enroll in the Medicare program and to receive provider identification numbers (PINs).

Radiologists should note that the updated 855 contains a specific requirement regarding diagnostic Radiology testing. Radiologists will rely on the new Forms 855 to accomplish a wide range of general tasks, including:

initially enrolling with each Medicare carrier to which they submit claims

updating information on a previously submitted 855 (.g., when a practice location is added)

deleting a provider number when it is no longer being used (e.g., when a radiologist leaves a group)

reactivating a provider number (e.g., when a adiologist returns after a leave of absence).

Radiologists do not need to immediately submit the new versions of the 855 forms to carriers they are enrolled with.

The revised forms were designed to fulfill three objectives:

1. Ease of use. Previous versions of the form mixed and matched information relating to Part A and Part B Medicare providers and suppliers, sections were redundant, and instructions were hard to follow. The new version resolves these issues and also standardizes enrollment across the country, according to Dennis Grindle, a partner with Seim, Johnson, Sestak & Quist, LLP, a national healthcare consulting firm based in Omaha, Neb. In the past, there have been no fewer than 125 different applications used by various Medicare carriers, fiscal intermediaries and durable medical equipment carriers.

2. Streamlining the credentialing process. The previous (1/98) version of the HCFA-855 will be exploded into three new, specific versions, explains Grindle. 855A will be used by hospitals, hospices, home health agencies and other Part A providers. 855B will be used by physician groups, independent diagnostic testing facilities, ambulatory surgical centers, physical therapy groups and other Part B suppliers. 855I will be completed by the individual radiologists, as well as other physicians and practitioners (e.g., physician assistants). He adds that Form 855I will also be used to revalidate or re-enroll radiologists with each Medicare carrier. Although regulations are still being finalized, this will probably need to be done about every three years.

Radiologists will also complete the 855R. This is the form physicians will fill out to reassign their rights to bill for services to an organization like a corporation, partnership or physician group, Grindle says.

Note: HCFA has also revised the 855S, which will continue to be used to enroll organizations billing for DME supplies, and will eliminate version 855C, now used for routine types of changes.

If more than 30 percent of the diagnostic tests performed by a radiologist involve Medicare patients referred by another physician, the radiologist must enroll as an independent diagnostic testing facility (IDTF) with Form 855B, in addition to enrolling as an independent provider with 855I. Grindle explains that HCFA is making a distinction between patients referred for diagnostic testing and patients considered to be the radiologists own patients.

3. Serve as proactive fraud and abuse tool. The new Forms 855 are designed to help Medicare better monitor claims. Radiologists, for example, must complete multiple forms and submit them to every Medicare carrier that has jurisdiction over the locations where services will be provided. If employed by a diagnostic imaging group practice in Washington, D.C., that also has satellite centers in the Maryland and Virginia suburbs, a radiologist may be required to fill out an 855I to receive distinct provider numbers from each individual carrier that has jurisdiction over Washington, D.C., Maryland, and Virginia. In addition, if the practice has multiple locations in any of those geographic regions, individual numbers will be assigned to identify each specific site. Claims could be scrutinized to ensure that the practice locations correlate to those reported by the radiologist. Otherwise, radiologists may be reporting services at locations that are not eligible for Medicare reimbursement.

The revised 855 may also contain one last piece of good news: The upcoming guidelines are expected to give carriers a maximum of 60 days to make a final decision on all enrollment applications, a big improvement over the past. This window includes getting additional information or clarification from the applicant.

Draft versions of the new Forms 855 can be downloaded from www.hcfa.gov/regs/prdact95.htm.