Radiology Coding Alert

Watch out: You could be one of the radiology practices losing out on reimbursement for Doppler exams performed with ultrasound.

To get a closer look at what will -- and won't -- fly when you have to back up your claims, evaluate the real-life order and report below. Then see what our experts Raymond E. Bertino, MD, FACR, FSRU, vascular and general ultrasound director for OSF Saint Francis Medical Center, radiology and surgery clinical professor at University of Illinois College of Medicine at Peoria, and Jackie Miller, RHIA, CPC, radiology coding expert and senior coding consultant for Coding Strategies, Inc., in Powder Springs, Ga., have to say about which codes you should and shouldn't assign on your claim.

Order: Transvaginal pelvic ultrasound, check endometriosis

Clinical: History of endometrial biopsy

Transabdominal as well as transvaginal including color Doppler evaluation of the pelvis was performed. The uterus is normal in size. The uterus is midline and anteverted and measures 8.8 x 3.2 x 5.6 cm. There is no intramural, endometrial or subserosal mass. The endometrial stripe is within the upper limits of normal measuring 6 mm. The cervix and vagina appear normal.

The uterus does contain multiple small fibroids. The largest fibroid measures 9 x 8 mm and involves the posterior body.

The left ovary is enlarged. The left ovary measures 3.5 x 2.5 x 2.3 cm. The left ovary is enlarged secondary to a complex left ovarian cyst measuring 2.7 x 2.2 cm. This is predominantly cystic but does have a nodular density within its base. The nodular density measures 1.1 x 1.5 cm. Doppler evaluation demonstrates a resistive index of 0.3 suggestive of low resistive blood flow.

The right ovary is normal measuring 2.2 x 1.1 x 1.0 cm.

There is no pelvic adenopathy or ascites.

Impression:

1. Enlarged left ovary secondary to a complex left ovarian cyst measuring 3.5 x 2.5 x 2.3 cm. This has a solid nodular density within it. Doppler evaluation demonstrates low resistive flow. Correlation with CEA as well as CA-125 levels is suggested. A follow-up study in 4-6 weeks is suggested to verify stability or resolution of this complex cyst.

2. Fibroid uterus as discussed above.

3. The endometrial stripe is within the upper limits of normal at 6 mm.

Although the sample order indicates only a transvaginal ultrasound, the report suggests at least three procedures, notes Bertino:

1. transvaginal ultrasound (TV US)

2. transabdominal ultrasound (TA US)

3. Doppler evaluation.

Reporting the TV US alone is the safest bet for the sample report, says Miller.

The cost: Medicare lists 3.08 transition facility total relative value units (RVUs) for 76830 (Ultrasound, transvaginal). Code 76856 (Ultrasound, pelvic [nonobstetric], real time with image documentation; complete) has 3.09 RVUs, and 93975 (Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study) has 10.4 RVUs.

If the radiologist had adequate documentation for the TA US and Doppler, that would add an additional 13.49 transitioned facility total RVUs. Multiply by a June 2008 conversion factor of 38.087, and that's roughly $514 lost before adjusting for geographic location.

What to do: Here's a look at how to bulletproof your documentation for Doppler and US, based on available guidelines.

IDTF: If you're in an independent diagnostic testing facility (IDTF), ordering rules are quite specific, says Bertino. "The IDTF would need to get a faxed order from the treating physician and this order would document the medical necessity of the exam," he says, citing Medicare Carriers Manual (MCM) Transmittal 1725, section 15021 (http://www.cms.hhs.gov/transmittals/downloads/R1725B3.pdf).

The rule: "The treating physician/practitioner must order all diagnostic tests furnished to a beneficiary who is not an institutional inpatient or outpatient. A testing facility that furnishes a diagnostic test ordered by the treating physician/practitioner may not change the diagnostic test or perform an additional diagnostic test without a new order," states MCM Transmittal 1725. Remember: A radiologist performing a therapeutic interventional procedure is a treating physician. A radiologist performing a diagnostic procedure is not, the same transmittal states.

In the hospital: If the provider performs the test in a hospital, the IDTF rules don't apply officially, Bertino points out.

Reason: In a hospital setting, the hospital may grant the radiologist the ability to order new tests (42 CFR section 482.26), but some fiscal intermediaries still may deny your claims unless you have an order from the treating physician.

Following the IDTF rules will help keep you compliant, Bertino notes, but following the rules can be tough in the hospital setting.

You won't find specific directions from Medicare saying whether you need separate orders for TV US, TA US and Doppler, notes Miller

The American College of Radiology (ACR) maintains that whether the radiologist performs TV, TA or both falls under the test design exception, Bertino says.

Test design explained: CMS rules allow radiologists some leeway in designing the diagnostic test. Specifically, MCM section 15021 (E)(1) states that "unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test (e.g., number of radiographic views obtained, thickness of tomographic sections acquired, use or non-use of contrast media)" (http://www.cms.hhs.gov/Transmittals/Downloads/R80BP.pdf).

Caution: CMS guidelines specify that the radiologist (interpreting physician) may determine test design not specified in the order, Miller says. The guidelines don't support allowing a technologist to determine test design parameters, she says.

Safe choice: Medicare pays roughly the same amount for the TA and TV studies, Miller says. An auditor may take the stance that the radiologist added an exam rather than simply made a test design change. So getting the order may be the safe bet if you're going to bill for both.

Whether the test design exception applies to the duplex (Doppler) code is uncertain, Bertino says.

The AMA and ACR (Clinical Examples in Radiology, Winter 2006) take the position that you don't need a separate order for the Doppler because it is a test design parameter, Miller says. They do caution, however, that routinely doing a Doppler on every patient would not be defensible, Miller adds. But you can perform the Doppler if it is "medically necessary based upon the clinical presentation and specific clinical question." If there is no order for the Doppler, the radiologist must document why the patient needed it, she says.

But again, CMS offers no specific guidance.

Best bet: If you're in an IDTF, getting an order for the Doppler is the safest route, Bertino says.

If you're in a hospital and don't get a separate order for the additional test, the radiologist should spell out the medical necessity for the additional test, Bertino says. You also may want to have a departmental policy indicating when to add duplex exams, such as for masses or pelvic pain, he adds.

Stay tuned: Next month, Radiology Coding Alert will reveal how to adequately document TV and TA US with Doppler in Part II.