Radiology Coding Alert

HCFA recently released a Program Memorandum (B01-28) updating its regulations governing physician supervision of diagnostic tests.

According to coding experts, the memorandum targets diagnostic tests that are performed outside of a hospital setting. These would include services provided in physicians offices and independent diagnostic testing facilities (IDTF) like imaging centers, says Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based firm that supports 1,000 radiologists and 350 multispecialty physicians.

Note: Diagnostic tests conducted on hospital patients are governed by separate guidelines contained in the Code of Federal Regulations.

Supervision Categorized in Three Levels

The Program Memorandum sets forth revised levels of physician supervision required for diagnostic tests payable under the Medicare Physician Fee Schedule . Section 410.32(b) of the Code of Federal Regulations, as adopted in the Medicare physician fee schedule final rule of Oct. 31, 1997, requires that diagnostic tests covered under 1861(s)(3) of the Social Security Act and payable under the Physician Fee Schedule, with certain exceptions listed in the regulation, have to be performed under the supervision of an individual meeting the definition of a physician (1861(r) of the Social Security Act) to be considered reasonable and necessary and, therefore, covered under Medicare.

This specific notice contains a long list of codes and indicates one of three categories of physician involvement that is necessary during outpatient diagnostic testing, explains Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm specializing in financial and healthcare management with a focus on physician compliance, coding, billing and reimbursement issues, based in Lansdale, Pa. The regulation defines levels of physician supervision for diagnostic tests as follows:

General Supervision The test is furnished under the physicians overall direction and control, but the physicians physical presence is not required during the procedure. Training of personnel and maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.

Direct Supervision The physician must be present in the office suite and immediately available to furnish assistance and direction throughout the procedure. This level does not require the physician be in the room during a diagnostic test.

Personal Supervision The physician must be in attendance in the room where the procedure is being performed.

In the Program Memorandum, general supervision is indicated with a 1, direct supervision with a 2, and personal supervision with a 3, Falbo notes.

These guidelines will raise questions in a number of areas, Parman says, and are likely to renew debate about what constitutes the immediate availability of the radiologist, as required with direct supervision.

Diagnosis Codes Must Support Cerebrovascular Ultrasounds Among the conditions that prompt cerebrovascular ultrasounds are cervical bruit, transient alchemic attacks, amaurosis fugax and dizziness. Some of the ICD-9 codes that support medical necessity include 435.0-435.9 (transient cerebral ischemia); 447.1 (stricture of artery); 780.02 (transient alteration of awareness); 362.34 (transient arterial occlusion, amaurosis fugax); 250.60-250.63 (diabetes with neurological manifestations); 250.70-250.73 (diabetes with peripheral circulatory disorders); 362.31-362.32 (retinal and arterial branch occlusion); 368.11 (sudden visual loss); 368.12 (transient visual loss); 434.00-434.91 (occlusion of cerebral arteries); 436 (acute, but ill-defined, cerebrovascular disease); 780.4 (dizziness and giddiness); 781.3 (lack of coordination); and 785.9 (other symptoms involving cardiovascular system, bruit). As always, approved diagnosis codes may vary from carrier to carrier, and coders should verify reportable ICD-9 codes with local payers.

Practices Should Note Surprises in Level Two

Parman recommends radiology practices pay particular attention to those outpatient diagnostic tests that require direct or personal supervision. Among the most noteworthy of the level-two codes listed are those describing computerized tomography (CT) and magnetic resonance imaging (MRI) done in an outpatient setting, she says. Parman says she has encountered freestanding facilities that occasionally perform these studies without a radiologist on site. Of course, this is an area that would require changes and would have a great impact on these facilities.

Included in the direct supervision requirement are:

70460 and 70460-TC computerized axial tomography, head or brain; with contrast material(s)(technical component)

70470 and 70470-TC without contrast material, followed by contrast material(s) and further sections (technical component)

70551 and 70551-TC magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material (technical component)

Similar codes for other sites on the body are also included under direct supervision guidelines. One reason these codes require this level of physician availability, Parman says, is that patients may suffer significant allergic reaction to the substances and contrast materials used during the test.

Radiologists should also recognize that, to comply with direct supervision guidelines, they must be in the office during the entire test. They cant simply be there when the test begins and then leave. That would not fulfill the requirement.

In some closely regulated instances, the radiologist may hire a proxy to be immediately available and on the premises. For example, an internist, emergency department physician or surgeon with a practice in the same site as the radiology facility may agree contractually to provide coverage for CT and MRI patients just as physicians may provide on-call coverage for one another in nonradiology settings. However, this practice is governed by strict requirements, like the presence of a written arrangement and acknowledgment by both physicians.

Most S&I Codes Require Personal Supervision

More important are the regulations affecting personal supervision (level three). Some of the outpatient diagnostic tests requiring this level come as no surprise, Parman says. Any code that contains the verbiage supervision and interpretation is typically performed by the physician and so personal supervision is a given. These services include angiography, myelography, cisternography, diskography, dacrocystography, arthrography, laryngography, sialography, bronchography, pacemaker insertion, peritoneogram, hysterosalpingography, ductogram, galactogram and guidance procedures.

However, the Program Memorandum also unexpectedly regards several other outpatient procedures as requiring personal supervision, including fluoroscopy codes 71034 (radiologic examination, chest, complete, minimum of four views; with fluoroscopy) and 71023 (radiologic examination, chest, two views, frontal and lateral; with fluoroscopy). In addition, virtually all gastrointestinal and genitourinary services demand personal supervision. These may come as something of a surprise to radiologists, Parman comments.

Falbo points out that the Program Memorandum includes some codes that were deleted in 2001 and therefore are no longer valid (e.g., 71036, needle biopsy of intrathoracic lesion, including follow-up films, fluoroscopic localization only, radiological supervision and interpretation).

Program Memorandum B01-28 can be downloaded from the HCFA Web site at www.hcfa.gov.