Radiology Coding Alert

CMS discovers sky-high error rate among these radiology codes.

Radiology coders have to be experts not only in knowing how to report x-rays and interventional procedures, but also ultrasounds, CT scans, and more. Unfortunately, Medicare’s latest report suggests that not all radiology coders have reached that “expert” status yet, and practices that are billing improperly may face paybacks down the road.

Background:  CMS released its “Appendices for the Medicare Fee-for-Service 2016 Improper Payments Report” in December as part of its Comprehensive Error Rate Testing (CERT) program. The report breaks down the most egregious errors among Medicare claims, and covers the causes of the improperly paid charges. Overall, the government found an 11.7 percent improper payment rate among Part B claims during 2016, with the vast majority of those being classified as overpayments to providers.

The majority of Part B errors were categorized as such due to insufficient documentation (totaling $5.5 billion in errors), while incorrect coding was also a major error source (costing $2.7 billion in errors). Medical necessity and no documentation errors were also seen among Part B claims. But it was radiology that took the biggest spotlight, because several subspecialties showed high error rates, according to the report.

Radiology Services Logged Over $200 Million in Part B Errors

When the government scrutinized radiology procedures, the results were startling. The CERT auditors found the following error rates among the Part B claims it audited:

When breaking down error rates by individual radiology subspecialists, CMS found that diagnostic radiology had the highest error rate at 9.7 percent, followed by portable x-ray suppliers at 9.6 percent and radiation oncology at 3.6 percent. Interventional radiologists logged the lowest Part B rates among the individual radiology specialists, with just 0.6 percent of claims coming into CMS with errors.

Here’s How to Avoid These Issues

Unfortunately, many of the practices that CMS found to be in error will find letters from their payers asking for money back.

Why? “If the insurer became aware that a practice coded incorrectly or maintained insufficient documentation to support their claims, that will lead them to recoup reimbursement from the practices that billed improperly, since the practices didn’t meet the criteria to have earned that reimbursement,” healthcare consultant Terri Orcala of Orcala Billing in Kansas City, Mo., tells Radiology Coding Alert.

Consider the following examples of improperly coded radiology claims so you can avoid a spot in CMS’ next improper payment report, and you can therefore hang on to your income.

Example 1:  You report 76881 (Ultrasound, extremity, nonvascular, real-time with image documentation; complete) for an ultrasound of the patient’s wrist to examine the ganglia for a possible cyst. The documentation to support the claim was as follows:

“Patient presents with a soft, mobile mass on the dorsal left wrist, with pain radiating up her arm when she picks up heavy objects. Performed an ultrasound of the left tendon, which revealed an 0.7 cm cystic structure on the ganglia. Performed a contralateral ultrasound of the right wrist for control and found that the right wrist was absent any cystic activity.”

Do you see the problem with this chart? The operative note is very detailed and thorough, but does not mention any examination of the entire extremity including muscles, joints, and other soft tissue structures, as CPT^® requires for 76881. Instead, the practice only examined the tendon of the left wrist for a medically necessary reason.

Therefore, this practice should have reported 76882 (Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific). CPT^® specifically says to use this code “to evaluate a soft-tissue mass that may be present in an extremity where knowledge of its cystic or solid characteristics is needed,” and also notes, “this is a limited examination of the extremity where a specific anatomic structure such as a tendon or muscle is assessed.”

Some practices may argue that the doctor did additional work by examining the right wrist for comparative purposes, but this does not warrant reporting 76881 and is actually not payable at all. Part B payer NGS Medicare’s policy says, “Bilateral studies are allowed only if there is pathology of both extremities dictating medical necessity for two distinct examinations. It is not reasonable and necessary to perform the contralateral extremity as a ‘control.’”

Therefore, the physician should report 76882 for the service with no modifiers or other codes. If you did report 76881 for this service and an auditor reviewed the documentation, you’d have to return the overpayment of $84.00 (the difference between the payment for 76881 [$120] and 76882 [$36]).

Example 2:  The practice performs a four-view x-ray of a patient’s left knee, including lateral and sunrise views in both standing and non-standing positions. You report 73564 (Radiologic examination, knee, complete, 4 or more views). The documentation for the claim simply says “Standing/non-standing left knee x-ray.”

Do you see the problem with this chart? The note is not thorough enough to support billing a four-view x-ray, because even though the radiologist may have circled 73564 on the claim, the documentation does not indicate that four views were taken. If a payer audited this note, you would likely be downcoded to 73560 (Radiologic examination, knee; 1 or 2 views), giving you credit for one view of the knee in standing position and one view in non-standing. Since 73560 pays about $31 and 73564 reimburses about $40, you’d have to refund $9.00 to the payer for this claim.

Resource: To read the full CERT document, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/AppendicesMedicareFee-for-Service2016ImproperPaymentsReport.pdf.