Radiology Coding Alert

No one likes to get caught making mistakes (least of all Medicare), but let's give them credit when they 'fess up. CMS has made adjustments to the Medicare Physician Fee Schedule database that allow radiology practices to resubmit claims and collect increased reimbursement a whopping additional 50 percent payment for certain procedures.

Medicare incorrectly assigned the "bilateral surgery" indicator to several codes. The effect was to reduce reimbursement for the second occurrence of each of these procedures by as much as 50 percent if the two procedures were performed bilaterally. The update corrects the problem and makes the correction retroactive to Jan. 1, 2002.

The code most affected within radiology is probably 75685 (Angiography, vertebral, cervical, and/or intracranial, radiological supervision and interpretation), says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc., an Atlanta-based firm.

Parman indicates that this code the global, professional-only and the technical-only designations used to have a bilateral modifier indicator of "0." According to the new transmittal, the bilateral modifier indicator is now set to "3." This means that the usual payment adjustment for bilateral procedures does not apply. Payment for these services when performed bilaterally will be based on the Fee Schedule amount as two separate services performed.

The Physician Fee Schedule explains indicator "3" by saying that if the procedure is reported with modifier -50 (Bilateral procedure) or is reported for both sides on the same day with -RT and -LT modifiers or with a 2 in the units field then you should receive payment for each side, organ, or site of a paired organ based on whichever is lower: a) the actual charge for each side or, b) 100 percent of the fee-schedule amount for each side.

In short, "It looks like you get paid 100 percent of the fee schedule for both sides if a bilateral procedure is performed," says Sherry Straub, RHIT, CCS, CCS-P, the coding and compliance manager at Esse Health in St. Louis.

Further, if the procedure is reported as a bilateral procedure and with other procedure codes on the same day, determine the fee-schedule amount for a bilateral procedure before applying any multiple-procedure rules. Services in category "3" are generally radiology procedures or other diagnostic tests that are not subject to the special payment rules for other bilateral surgeries.

In other words, "there is a technical and professional breakdown on this code so both -TC and -26 can be used," Straub says. If the procedure was performed bilaterally, "I would use modifiers -LT and -RT for each side rather than -76 (Repeat procedure by same physician) on the second code. If, for example, you're billing for a repeat angiography on the same side, then you would use -76 on the second code."

While this appears to be a positive change for radiology, Parman notes, savvy radiology groups and facilities previously may have found ways to "work around" Medicare's oversight prior to the correction.

Even bigger news in the memorandum involves the changes to four codes: