Radiology Coding Alert

Many coding and billing professionals view HCFAs national relative value unit (RVU) file as a tool to determine payment for Medicare-covered services. However, this document is brimming with additional information essential to proper coding such as global periods, reporting bilateral and unilateral services, and splitting procedures into technical and professional components.

HCFA updates the RVU file annually and posts it on its Web site (www.hcfa.gov). There is a lot of valuable information coders can have right on their desktop, simply by downloading the file, points out Jennifer Butler, billing operations manager with Arizona Medical Provider Services Inc., in Cottonwood, Ariz., which provides billing and management services to radiology practices in Arizona.

Directions for downloading the RVU file used for this article are on the insert accompanying this issue. The RVU file was also published in the November 2000 Federal Register. However, that version appears in a modified format, and column headings differ from those downloaded from HCFA and appearing in this story.

Columns A, B, C and D

Each column of the RVU file provides information of value to coders. The fields explained below are those that most affect radiology coding. Those that dont appear have minimal impact.

Column A lists the codes, while Column C contains abbreviated code descriptions. Column B (modifiers) identifies whether the code has a professional or technical component (modifier -26 [professional component or PC] or modifier -TC [technical component]), Butler says. If a code has both TC and PC portions and the field is blank, it generally means that the service is global. There are some exceptions to this, however, like 76012 and 76013. These codes, added in 2001 to describe vertebroplasty imaging, are listed without modifiers, but are for the professional component only.

Some codes may be reported any of these three ways, Butler notes, such as CPT 73500 (radiologic examination, hip, unilateral; one view), which appears three times in the file once with no indication in the Modifier column, once with TC and once with modifier -26. (See insert.) A radiologist who owns x-ray equipment and interprets the films would assign 73500 globally, while the radiologist who interprets the x-rays taken at a hospital-owned facility would code 73500-26.

Column D indicates the current status of the code. An A indicates the code is active, while R represents restrictions where special coverage instructions apply (e.g., carrier-priced). A status indicator D (e.g., 70541, head and neck magnetic resonance angiography) shows that it has been deleted, explains Anne Masters, a radiology coding specialist who works with Butler.

Codes designated with an I represent codes that are not valid for Medicare. Alternately, they may be reported with HCPCS Level II codes. Code 78459 (myocardial imaging, positron emission tomography [PET], metabolic evaluation), for instance, is designated with an I. This service would be reported with a code from the HCPCS G0030-G0047 series for Medicare beneficiaries.

Less common designations include C (e.g., 77499, unlisted procedure, therapeutic radiology treatment management), indicating that local carriers determine the fee allowance; B, signifying that the code is bundled into another primary procedure; and N, indicating codes not covered by Medicare.

Determining Relative Value Units

Relative value units found in 10 fields ranging from F to P are the foundation for calculating Medicare payments. Three components physician work, practice expense and malpractice expense are added together to produce the RVU total. Physician work (Column F) and malpractice (Column L) RVUs occupy one column each, but practice expense may vary depending on whether the service is performed in a facility (i.e., hospital) or nonfacility (i.e., office).

Additionally, both facility and nonfacility practice expense RVUs are listed two ways: transitioned and fully implemented. The difference relates to HCFA adjustments of fees paid for procedures over a four-year cycle that began in 1998. For procedures or services performed in 2001, only the transitioned column applies. In 2002, when HCFAs fee schedule changes are in place, the fully implemented column will be correct.

The file also provides the total number of RVUs for each procedure, so coders do not have to add the columns. There are four columns with this information (Columns M-P), again relating to the setting (facility or nonfacility) in which the procedure or service was performed and including both transitional and fully implemented fees.

For example, the correct number of RVUs (7.22) for a complete diagnostic ultrasound of a pregnant uterus (76810) performed in a facility is found in Column P, which lists the transitioned total RVUs for services performed in a facility (see sample on enclosed insert).

There are also geographic practice cost indices (GPCIs) used to correct the RVUs on a regional basis. Because there are separate GPCIs for work, practice expense and malpractice, GPCI corrections cannot be applied to the total RVU column. Rather, they must be made to each of the three specific RVUs, which are then added to determine the GPCI corrected total. This number is then multiplied by the current national conversion factor ($38.2581 in 2001) to arrive at the Medicare fee schedule expected payment (see GPCI sidebar).

Coders should remember that RVUs are not meant to guide physicians on how much to bill. Because some payers exceed Medicares fee schedule, coding experts agree that radiologists should bill based on internal fee calculations and not use Medicares fee as a baseline.

Global Periods and Multiple Procedures

Columns R, S, T and U provide information about global periods. Column R indicates the number of global days HCFA assigns to a procedure or service. Coders who work with interventional practices may be familiar with 0-, 10- or 90-day global periods. For instance, they may assign 47510 (introduction of percutaneous transhepatic catheter for biliary drainage), which carries a 90-day global period.

In addition, the RVU file includes procedures with global periods XXX (the global concept does not apply), YYY (carrier determines coverage and pricing, and global period applies), and ZZZ (the code is related to another service and is always included in the global period of the other service). The XXX designation typically applies to diagnostic tests, such as 74000 (radiologic examination, abdominal; single anteroposterior view), while ZZZ may be listed for some add-on codes, such as 22522 (percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body). Only unlisted codes receive YYY designation.

Column V indicates how a procedure should be paid if it is not the primary procedure performed during the session. Radiologic diagnostic tests, such as x-rays, usually include an indicator of 0, meaning that no payment adjustment is made and the service is paid at 100 percent even if it was performed at the same time as another service. Interventional procedures, on the other hand, may have an indicator of 2, indicating that the standard multiple-procedure payment rule applies (100 percent for the highest-paying procedure, 50 percent for all the others).

Bilateral Procedures

Column W tells physicians and coders how a procedure should be paid if it is performed on both sides. Procedures that cannot be billed as bilateral simply because two sides do not exist (e.g., 76805 to describe a uterine ultrasound) will show a 0 in column W. Alternatively, if the procedure can be performed on two sides and there are distinct codes for the procedure when performed bilaterally and unilaterally, the unilateral procedure will show a 0 in column W as well (i.e., 73500, radiologic examination, hip, unilateral; one view).

If the procedure shows a 1 in column W and is reported with modifier -50 (bilateral procedure) or by any other means such as -RT (right side) and -LT (left side) modifiers or with a 2 in the units field of the HCFA 1500 claims form there is a 150 percent payment adjustment, says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions in Lakewood, N.J.

If column W contains a 2 (e.g., 73050), no fee adjustment should be made because the RVUs for the code assume a bilateral procedure. In the rare event that a procedure performed bilaterally includes a 3 in column W (73220), both sides should be billed at 100 percent, for a total of 200 percent. A 9 in column W (73225) indicates that the concept of bilateral procedure does not apply.

Calculating Medicare Payments From RVUs and GPCIs By definition, geographic practice cost indices (GPCIs) differ from region to region. Here is an example of how a single-view chest x-ray would be calculated in Ohio. Procedure: A chest x-ray (71010-26), performed in a facility (hospital-based); transitional for 2001 Work Practice Expense Malpractice National RVU: 0.18 0.07 0.01 Ohios GPCI: 0.989 0.942 1.016 To determine the total RVUs for Ohio, multiply the national RVU by the Ohio GPCI, and add: Work: 0.18 x 0.989 = 0.178 PE: 0.07 x 0.942 = 0.0659 MP: 0.01 x 1.016 = 0.0102 TOTAL: 0.2541 To calculate the actual fee schedule amount for a single view of the chest, multiple the GPCI-corrected total RVU by the national conversion factor of $38.2581. This reveals that the anticipated Medicare payment would equal $9.72 in 2001.