Radiology Coding Alert

Knowing when and how to report various HCPCS Level II or Level III 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. "The only time a physician or radiology group should code and bill separately for contrast is when the professional entity bears the cost of purchasing the supplies," says Melody W. Mulaik, MSHS, CPC, RCC, president and co-founder of Coding Strategies Inc. in Atlanta. Therefore, the contrast may be considered a separately billable service when the radiology services are provided "with contrast."

But, outside of some A codes, there aren't that many codes that are still billable, says Craig McNabb, MBA, BSN, reimbursement manager for radiation for the Atlanta branch office of US Oncology, based in Houston. "This isn't a Happy New Year present, at all."

The Supplies for Radiologic Procedures section of HCPCS Codes contains a list of codes that freestanding and independent facilities may use. Four of the codes relate directly to contrast agents used during magnetic resonance imaging (A4643), computed tomography scans (A4644-A4646), as well as other diagnostic procedures that use iodinated contrast material:

When considering whether to report any of these supplies, coders must first look at who purchased them. Only the entity that bears the cost of purchasing supplies may bill for them, Mulaik says.

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.

Of these, the codes for low osmolar contrast material (LOCM) are the most frequently used. According to CMS, LOCM has always been covered, regardless of diagnosis, Mulaik says, although hospitals have their reimbursement bundled into facility payments. She notes that CMS has further indicated that a beneficiary is not ever responsible for paying for any LOCM delivered in a HOPPS setting.

Besides local carrier policy, 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.

Nuclear Medicine A Codes

A number of the A codes including A4641, A4642, A4647, A9500-A9507 and A9600-A9605 are closely associated with nuclear medicine procedures. These may be reported in addition to the relevant procedure codes when they are being conducted by independent or freestanding facilities, says Kenneth A. McKusick, MD, FACR, nuclear medicine specialist now retired from the Massachusetts General Hospital and chairman of the Nuclear Medicine APC Task Force representing the Society of Nuclear Medicine (SNM).

On Nov. 1, 2002, CMS presented a new policy on payment for radiopharmaceuticals (RPs), bundling them into the payment for the diagnostic procedure performed (editor's note: See 67 Fed. Reg. 66757). The Nuclear Medicine and APC Task Force headed by McKusick recently published a strongly worded memorandum objecting to CMS' "radical change in Medicare payment policy, suggesting that radiopharmaceuticals are not drugs" and requesting a meeting.

For a short time, hospital-based nuclear medicine departments could report RPs used during outpatient procedures. This was an exception to the standard hospital outpatient prospective payment system (HOPPS), instituted on Aug. 1, 2000, which reimburses most outpatient services at a flat rate determined by ambulatory patient classifications (APCs). The flat fee replaces the practice of billing individual CPT or HCPCS codes.

The Balanced Budget Act of 1999 recognized RPs as a special class of products eligible for the pass-through because they contain specialized radioisotopes that have short half lives and require special handling. But, "the procedures now generally include the cost of the RP," McKusick says.

McKusick and the task force met with representatives from CMS on Dec. 13, 2002, and specifically discussed adding certain RPs in the $150-plus range to the pass-through list. After the meeting, McKusick has a clear message for billing RPs in outpatient settings under HOPPS. "It is extremely important that the hospital report to CMS their cost for doing that procedure, including the RP," he insists.

For APC reimbursement, hospitals should continue to report each cost separately, the experts agree, even when it is not separately reimbursed under APCs, to ensure that the revenue codes are captured and used to factor APC reimbursement adjustments in the future.

Case Study:Billing Gadolinium

With all the changes afoot, coders often wonder when it is appropriate to bill for gadolinium and other MRI-related radiopharmaceuticals along with an MRI code that includes a "with and without contrast" description.

Most coding experts, along with Medicare, do not advise practices to report A4647 (Supply of paramagnetic contrast material [e.g., gadolinium]) or other paramag-netics for the contrast media with an MRI e.g., 70553 (Magnetic resonance [e.g., proton] imaging, brain [including brain stem]; without contrast material, followed by contrast material[s] and further sequences).

In general, you should not be billing for any contrast material with an MRI, McNabb says. One exception may occur on those rare occasions when a double dose of contrast is used during an MRI of the brain. In this case, you may report A464x, or the code that accurately reflects the contrast administered. Coders should check first with individual payers for their policies regarding contrast materials.