Transcript Slide 1

The Treasure Hunt—Keys to Unlocking
Radiology Reimbursement PAYMENT
Walt Blackham, MS, RCC
Radiology Business Management Association, RBMA
THE ROLE OF CODING
Communication between
 You, the healthcare provider)
and the
 Payer
 The Patient
 The insurance Company
 Some other third party
Correct Coding: Why Bother?
THE ROLE OF CODING
 Proper coding is the initial (and
most important) step in the process
of obtaining correct payment for the
services you provide.
 Proper coding is the first building
block for Corporate Compliance
THE ROLE OF CODING
 Coding is a unique language
THE ROLE OF CODING
CPT 4
 Current
Procedural Terminology
 AMA code set for physician services
 Describes what you did
 Under HIPPA CPT is the uniform
coding set
 CPT 5 in development
THE ROLE OF CODING
CPT
5
digit alphanumeric code set
• Category 1 from 00100-99602
• Category 3 - 0016T-0170T
2
digit modifiers
• “…indicate that a service or procedure that has
been performed has been altered by some
specific circumstance but not changed in its
definition or code.”
THE ROLE OF CODING
CPT
 Rules of procedure coding
 “Select
the name of the procedure or
service that accurately identifies the
service performed.”
 “Do not select a CPT code that merely
approximates ……”
THE ROLE OF CODING
CPT
 Rules of procedure coding
 “If
no such procedure or service exists,
then report the service using the
appropriate unlisted procedure or service
code. “
New CPT Codes
• Application from the AMA with clinical
vignettes
• Usually handled thru the medical
professional societies
• CPT Advisory Committee
• CPT Editorial Panel
• AMA/Specialty RVS Update Committee (RUC)
Level II HCPCS
 Medicare alphanumeric codes for;
 Procedures e.g. digital mammography
 Non-Ionic Contrast
 Radiopharmaceuticals
 Other drugs and codeable supplies
THE ROLE OF CODING
ICD-9-CM
 Diagnosis codes describe why you
did the particular CPT code
THE ROLE OF CODING
ICD-9-CM
 3 to 5 digit alphanumeric codes
 001.0
through 999.9
 V01.0 through V86.1
THE ROLE OF CODING
For proper ICD-9 Coding code:
A. Highest Level of Specificity
Use 4th and 5th digits when available
B. Highest Level of Certainty
Code positive results if relevant to the
encounter
THE ROLE OF CODING
 As specified in §4317(b) of the
Balanced Budget Act (BBA), referring
physicians are required to provide
diagnostic information to the testing
entity at the time the test is ordered.
THE ROLE OF CODING
 PAIN!!!!!!
 The Central Office for ICD-9-CM has sent a
letter in stating that The Cooperating Parties
of ICD-9-CM (AHA, AHIMA, CMS, NCHS)
“..agreed that since the x-ray was specific to a
site (in this case, the neck), the more specific
code for “neck pain” or 7231, Cervicalgia,
may be assigned as the reason for the x-ray.”
THE ROLE OF CODING
 According to the *Official Guidelines for
Coding and Reporting* (Section IV), in
the outpatient setting, diagnoses
documented as ‘probable,’ ‘suspected,’
‘questionable,’ ‘rule out,’ or ‘working
diagnosis’ are not coded. Rather, code
the condition(s) to the highest degree of
certainty for that encounter/visit, such as
symptoms, signs, abnormal test results,
or other reason for the visit.”
THE ROLE OF CODING
 “These terms
[‘consistent with,’ ‘compatible with,’
‘indicative of,’ ‘suggestive of,’ and
‘comparable with’]
fit the definition of a probable or
suspected condition”
THE ROLE OF CODING
“On the rare occasion when the
interpreting physician does not have
diagnostic information as to the reason
for the test and the referring physician is
unavailable to provide such information
,it is appropriate to obtain the
information directly from the patient or
the patient’s medical record if it is
available.”
DOCUMENTATION MODEL
 Model based on ACR Practice Guideline
for Communication of Diagnostic
Imaging Findings
 Demographics
• Patient Identifiers, name, ID #
• Facility Name / location
• Referring Physician name
• Date of Exam
• Etc.
DOCUMENTATION MODEL
 Name
or type of Examination
Use terminology as listed in CPT
Plain films - specify number of views
CT & MR - without, with or with and without
contrast
SPECIFY WHICH FOR EACH
EXAMINATION
Nuclear Medicine - CPT name not
radiopharmaceutical name
Note: If a combination of services are
performed in the same session, each should
be separately dictated and documented in the
written report
DOCUMENTATION MODEL
 Time
of Exam Where Appropriate
 Multiple portable chests on the same
day
DOCUMENTATION MODEL
 Reason
for the Exam
Relevant Clinical Indicator
Cannot use rule-out or probable
diagnosis for billing
For billing must have signs and
symptoms, for example, pain or injury if
exam is negative
However, The MORE clinically
information the better.
DOCUMENTATION MODEL
 Body
of Report
 Impression or Conclusion
• Except if report is very brief
 Rendering
radiologist’s name
The Radiology Report
 If you can’t read it, you can’t code it.
Questions?
Walter C. Blackham, MS, RCC
President and CEO
Specialty Medical Services, Inc.
221 West 8th Street
Lorain, OH 44052-1817
[email protected]
440.245.8010 Ext. 10