Radiology Coding Alert

Knowing when and how to report various level II or HCPCS Codes is crucial if freestanding imaging centers and independent diagnostic testing facilities are to receive speedy and appropriate reimbursement for the medical supplies they provide. Radiology coders in freestanding and independent facilities may often report medical supplies purchased, as long as carrier restrictions are met.

In my experience working with radiology coders, how to properly assign the codes listed in the Supplies for Radiologic Procedures section of the HCPCS Manual is always a topic for discussion, says Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc, an Atlanta-based firm that supports 1,000 radiologists and 350 physicians from other specialty areas. Fortunately, there are a number of resources that can help coders find the answers they need.

The Supplies for Radiologic Procedures section contains a number of codes that freestanding and independent facilities may use, including:

A4641 supply of radiopharmaceutical diagnostic imaging agent, not otherwise classified

A4642 supply of satumomab pendetide, radiopharmaceutical diagnostic imaging agent, per dose

A4643 supply of additional high dose contrast material(s) during magnetic resonance imaging, e.g., gadoteridol injection

A4644 supply of low osmolar contrast material (100-199 mg of iodine)

A4645 supply of low osmolar contrast material (200-299 mg of iodine)

A4646 supply of low osmolar contrast material (300-399 mg of iodine)

A4647 supply of paramagnetic contrast material (e.g., gadolinium)

A4649 surgical supply; miscellaneous

A9500 supply of radiopharmaceutical diagnostic imaging agent, technetium Tc 99m sestamibi, per dose

A9502 supply of radiopharmaceutical diagnostic imaging agent, technetium Tc 99m tetrofosmin, per unit dose

A9503 supply of radiopharmaceutical diagnostic imaging agent, technetium Tc 99m, medronate, up to 30 mCi

A9504 supply of radiopharmaceutical diagnostic imaging agent, technetium Tc 99m apcitide

A9505 supply of radiopharmaceutical diagnostic imaging agent, thallous chloride TL-201, per mCi

A9507 supply of radiopharmaceutical diagnostic imaging agent, indium IN 111 capromab pendetide, per dose

A9600 supply of therapeutic radiopharmaceutical, strontium-89 chloride, per mCi

A9605 supply of therapeutic radiopharmaceutical, samarium sm 153 lexidronamm, 50 mCi

Note: For a comprehensive list of Level II radiopharmaceuticals, see the Nov. 16, 2000, Federal Register.

When considering whether to report any of these supplies, Parman says, coders must first look at who purchased them. Only the entity that bears the cost of purchasing supplies may bill for them. Radiologists who practice in a hospital setting, for instance, would not bill for these supplies, since the hospital would be the agent purchasing them. Freestanding centers, on the other hand, would buy the materials directly and therefore may report them along with any relevant procedural or supervision and interpretation codes.

Carriers Limit Reimbursement

Four of the codes relate directly to contrast agents used during magnetic resonance imaging (A4643), computer tomography scans (A4644-4646), as well as many other diagnostic procedure using iodinated contrast material. Of these, the codes for low osmolar contrast material (LOCM) are the most frequently used.

Note: Coders must recognize that the more typical ionic or high osmolar contrast materials are not coded and billed separately. These materials are considered bundled into the procedural code that describes the diagnostic imaging service being provided.

There are a number of factors coders need to bear in mind as they use A4644-A4646, Parman says.

To begin with, she points out, they are subject to local carriers policies. When coders look at the HCPCS manual closely, they will see notations indicating some of the restrictions. Use of low osmolar contrast is typically allowable only with patients who have a history of allergy to contrast material, asthma or significant cardiac dysfunction. Specific diagnosis coding guidelines will be found within local medical review policies (LMRPs).

A review of several LMRPs uncovered relatively consistent guidelines for use of LOCM. Local Medicare carriers in Florida, North Carolina, Pennsylvania, Louisiana, New York, Tennessee, Wisconsin and Nebraska, for instance, list the following indications:

history of asthma or allergy

significant cardiac dysfunction, including recent or imminent decompensation, severe arrhythmia, unstable angina pectoris, infarction and pulmonary hypertension

generalized severe debilitation

sickle cell disease

history of previous adverse reaction to contrast material with the exception of a sensation of heat, flushing or a single episode of nausea and vomiting.

Others may add additional indications, as is the case with the Iowa carrier, which also allows LOCM in patients with renal dysfunction and patients who must remain immobile during injection for image clarity (e.g., those undergoing angiography of distal extremities).

Parman adds that it is vital that radiologists document conditions that require the use of LOCM. A lot of facilities prefer to use LOCM because many patients find it easier to tolerate, she cautions. But the conditions that indicate medical necessity must truly exist and be clearly documented. Carriers are on the lookout for facilities where the last 50 patients coincidentally have had an allergic reaction to contrast or are asthmatic.

Take Time to Read the HCPCS Manual

Besides local carrier policy, Parman points out that descriptions in the HCPCS manual direct coders to specific Medicare Carriers Manual (MCM) references. These are found in Appendix B of the HCPCS guide. The radiological A codes contain references to MCM 15022 and 15030. These contain a wealth of information for coders.

Sections F1 and F2 within MCM 15022, for instance, contain very specific details about payment criteria and payment levels as they affect LOCM.

I urge coders to take a few minutes to really look at all the information that can be found in the HCPCS manual itself, Parman says. Many coders tell me they dont know how to bill these A codes but most of the information they need can be found in the back of the manual.

Coding Radiopharmaceuticals

A number of the A codes including A4641, A4642, A4647, A9500-A9507 and A9600-A9605 are associated with nuclear medicine procedures. These too may be reported in addition to the relevant procedure codes when they are being conducted by independent or freestanding facilities, according to Kenneth A. McKusick, MD, FACR, nuclear medicine specialist now retired from the Massachusetts General Hospital and a member of the American Medical Association CPT Advisory Committee representing the Society of Nuclear Medicine (SNM). A separate HCPCS code is assigned for each radiopharmaceutical (RP) employed during the procedure, he explains.

For the time being, McKusick adds, hospital-based nuclear medicine departments may also report radiopharmaceuticals used during outpatient procedures. This is an exception to standard outpatient billing, which is now governed by HCFAs hospital outpatient prospective payment system (HOPPS), instituted on Aug. 1, 2000. Under HOPPS, most outpatient services are reimbursed at a flat rate determined by ambulatory patient classifications (APCs), which are intended to compensate for physician services, nursing, room charges and supplies. The flat fee replaces the practice of billing individual CPT or HCPCS codes.

However, McKusick says, certain materials including radiopharmaceuticals used in nuclear medicine are eligible for temporary transitional pass-through payments that are reported in addition to the APC rates. The Balanced Budget Act of 1999 recognized RPs as a special class of products eligible for the pass-through because RPs contain specialized radioisotopes that have short half lives. Consequently, hospitals must implement unique, and sometimes costly, controls for safe storage, handling and administration to protect patients and technicians, he points out.

This will likely change soon, McKusick adds. The cost of RPs will likely be rolled into the procedure APC after a couple of years. Therefore, it is crucial that outpatient nuclear medicine departments report all of the RP and supply codes. This information will be tracked throughout 2001, and adjusted APC rates will be based on this information. At this time, RPs are being paid at 95 percent of the average wholesale price, he says.