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Conference Name:
Radiology Orders for Diagnostic Testing: Appropriate documentation for
proper reimbursement
Scheduled Conference Date:
Tuesday, April 25th, 2006
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presents . . .
Radiology Orders for Diagnostic
Testing: Appropriate
documentation for proper
reimbursement
A 90-minute interactive audioconference
Tuesday, April 25, 2006
1:00 p.m.–2:30 p.m. (Eastern)
12:00 p.m.–1:30 p.m. (Central)
11:00 a.m.–12:30 p.m. (Mountain)
10:00 a.m.–11:30 a.m. (Pacific)
In our materials, we strive to provide our audience with useful, timely information. The live audioconference
will follow the enclosed agenda. Occasionally our speakers will refer to the materials enclosed. We have
noticed that other non-HCPro audioconference materials follow the speaker’s presentation bullet-by-bullet,
page-by-page. Because our presentations are less rigid and rely more on speaker interaction, we do not
include each speaker’s entire presentation. The materials contain helpful forms, crosswalks, policies, charts,
and graphs. We hope that you find this information useful in the future.
HCPro is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations,
which owns the JCAHO trademark.
ii
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
The “Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement” audioconference materials package is published by HCPro, 200 Hoods Lane, P.O. Box
1168, Marblehead, MA 01945.
Copyright 2006, HCPro, Inc.
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For more information, contact
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Fax: 781/639-0179
E-mail: customerservice@hcpro.com
Web site: www.hcpro.com
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
iii
200 Hoods Lane
P.O. Box 1168
Marblehead, MA 01945
Tel: 800/650-6787
Fax: 800/639-8511
Dear colleague,
Thank you for participating in our “Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement” audioconference with Stacie L. Buck, RHIA, LHRM, and
Stacy M. Gregory, RCC, CPC, moderated by Melissa Varnavas.
We are excited about the opportunity to interact with you directly
and encourage you to take advantage of the opportunity to ask our
experts your questions during the audioconference. If you would like
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line. We cannot guarantee that your question will be answered during the program, but we will do our best to take a good cross-section of questions.
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might improve our audioconferences, or if you have any questions about
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please contact our Customer Service Department at 800/650-6787.
Along with these audioconference materials, we have enclosed a fax evaluation. We value your opinion. After the audioconference, please take a
minute to complete the evaluation to let us know what you think.
Thanks again for working with us.
Best regards,
Abigail Gresla
Associate producer
Fax: 781/639-2982
E-mail: agresla@hcpro.com
iv
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
Contents
Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi
Speaker profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
Exhibit A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Presentation by Stacie L. Buck, RHIA, LHRM, and Stacy M. Gregory, RCC, CPC
Exhibit B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47
Medicare’s Requirements for Ordering Diagnostic Tests
Exhibit C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
Incomplete Test Orders Tracking Sheet
Exhibit D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
ICD-9-CM Coding Requirements for Diagnostic Tests
Exhibit E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56
Ordering Mammograms: Screening vs. Diagnostic
Exhibit F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
Modifier -59 Decision Tree
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
v
Agenda
I.
II.
III.
IV.
V.
VI.
VII.
vi
Overview of radiology documentation challenges
Diagnostic test order guidelines
Radiology report documentation guidelines
CPT coding and documentation duidelines
ICD-9 coding guidelines for diagnostic test
Medical necessity for diagnostic tests
Live Q&A
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
Speaker profiles
Stacie L. Buck, RHIA, LHRM
Stacie L. Buck, RHIA, LHRM, is vice president of Southeast Radiology Management in Stuart, FL.
Stacie has served in several different roles during her 14-year career in health information management including as a medical records coordinator, medical coder, a revenue analyst, an internal auditor, corporate compliance officer, and consultant.
Stacie is on the editorial advisory board for the HCPro newsletters Mammography Regulation
Report, Radiology Administrator's Compliance Insider, Health Care Auditing Strategies and she is a
frequent contributor to Strategies for Health Care Compliance and to Compliance Monitor Q & A's
Ask the Expert. In addition, she is the author of the recently released Radiology Technologist's
Coding Compliance Handbook, Medical Necessity Training Handbook for Physicians, Medical
Necessity Training Handbook for Nurses and Hospital Staff and the ABN Training Handbook for
Physician Practices.
This year Stacie was the recipient of several awards including the 2005 AHIMA Rising Star Award,
FHIMA Outstanding Professional Award & FHIMA Literary Award. She currently serves on the
FHIMA Board of Directors and is President-Elect for the Suncoast Health Information Management
Association.
Stacy M. Gregory, RCC, CPC
Stacy M. Gregory, RCC, CPC, is currently employed as a charge capture and reconciliation specialist at Franciscan Health Systems in Tacoma, WA. Gregory is an accomplished radiology coder,
consultant and charge capture specialist with a sincere passion for coding and compliance.
In her seven years of experience with radiology coding and billing, Gregory has served as a billing
manager, medical coder, coding manager, educator, revenue support specialist, and consultant. She
has been an active member of various radiology coding discussion groups and has been featured in
several well-recognized coding publications, including The Coding Institute’s Radiology Coding Alert.
Gregory is the sole proprietor and senior consultant for Gregory Medical Consulting Services, also
based in Tacoma. She is a member of numerous professional organizations and actively participates
in continuing education opportunities for all areas of her field.
Melissa Varnavas (moderator)
Melissa Varnavas is a managing editor for the compliance market at HCPro, Inc. She edits Radiology Administrators’ Compliance & Reimbursement Insider as well as the e-zines Imaging
Weekly and Stem Cell Regulation Report.
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
vii
Exhibit A
Presentation by Stacie L. Buck, RHIA, LHRM, and Stacy M. Gregory, RCC, CPC
EXHIBIT A
Radiology Orders for Diagnostic
Testing: Appropriate
documentation for proper
reimbursement
Presented by:
Stacie L. Buck, RHIA, LHRM
Stacy Gregory, CPC, RCC
1
Overview of Radiology Coding
Challenges
• Documentation
Making sure physicians, technologists and coders
understand & adhere to the CPT, CMS and ACR
documentation requirements
• Medical Necessity
What is the reason the exam is being performed? Was it
ordered by a physician? Does it really need to be done?
• Integration/Collaboration
Developing a partnership between coding staff and
physicians for overall organizational success
2
2
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
Overview of Radiology
Documentation Challenges
•
•
•
•
Doppler vs. Duplex
CT vs. CTA
3D Reformatting/Reconstructions
Contrast materials
Oral or IV? What type/strength? How much?
• Permanent Images
What constitutes a “permanent image”?
How long must the image be stored?
Does this need to be documented in the radiology report?
• Supervision and Interpretation (S&I)
• PET and PET/CT
3
Overview of Radiology
Documentation Challenges
• The “Golden Rule”:
“If it isn’t documented, it didn’t
happen!”
4
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
3
EXHIBIT A
Whistleblower Case
• June 23, 2004 – DOJ announced that Radiology
Regional Center, PA, (FL) had agreed to pay $2.5 million
to settle charges that it filed false Medicare claims.
• The suit alleged that the group billed for numerous
studies that treating physicians did not order or
otherwise were not reimbursable.
– Retroperitoneal ultrasound procedures (76770)
– Noninvasive physiologic studies of the extracranial arteries and
extremity veins performed in conjunction with duplex scans of
the same arteries and veins (93875/93880, 93965/93970,
93965/93971)
– magnetic resonance imaging (MRI) of the orbit, face and neck
– reconstruction imaging (76375)
– Mammograms that the DOJ alleged did not qualify as diagnostic
and should have been billed as screening mammograms
Source: ACR Coding Source, July/Aug 2004
5
Lessons from the Florida Case
• Ordering of Diagnostic Tests - practices must know what
rules apply to each place of service (ie, hospital vs.
freestanding vs. office setting).
• Reinforces the need for radiologists to communicate with
referring physicians and to document their efforts to
obtain adequate orders and clinical indications when
necessary for a requested study—even if the referring
physician or office fails to provide such vital information
• Shows the value of a useful compliance plan that follows
the OIG model guidance for physician practices
Source: ACR Coding Source, July/Aug 2004
4
6
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
Why the confusion?
• Different rules for different settings
– Hospital
– Provider Based
– IDTF
7
Diagnostic Test Orders
Guidelines
8
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
5
EXHIBIT A
42 CFR 482.26
• Radiology services must be provided only
on the order of practitioners with clinical
privileges, or consistent with state law, or
other practitioners authorized by the
medical staff and governing body to order
the services.
9
42 CFR 410.32
• All diagnostic x-ray tests, diagnostic laboratory
tests, and other diagnostic tests must be ordered
by the physician who is treating the beneficiary,
that is, the physician who furnishes a
consultation or treats a beneficiary for a specific
medical problem and who uses the results in the
management of the beneficiary’s specific
medical problem.
• Tests not ordered by the physician who is
treating the beneficiary are not reasonable and
necessary
10
6
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
42 CFR 410.32
• Mammography exception. A physician
who meets the qualification requirements
for an interpreting physician may order a
diagnostic mammogram based on the
findings of a screening mammogram even
though the physician does not treat the
beneficiary.
11
42 CFR 410.33 - IDTFs
• All procedures performed by the IDTF must be
specifically ordered in writing by the physician
who is treating the beneficiary
• The supervising physician for the IDTF may not
order tests to be performed by the IDTF, unless
the IDTF’s supervising physician is in fact the
beneficiary’s treating physician.
• IDTF may not add any procedures based on
internal protocols without a written order
from the treating physician.
12
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
7
EXHIBIT A
Common Questions
• Does the referring physician need to
include signs/symptoms or a diagnosis?
• What constitutes an order?
• Can a testing facility modify an order?
• Can a testing facility perform additional
tests if necessary?
• Are there any exceptions to the rules?
13
Does the referring physician need to include
signs/symptoms or a diagnosis?
• Section 4317(b) of the Balanced Budget Act
(BBA), requires referring physicians to provide
this diagnostic information to the testing entity at
the time the test is ordered. If the referring
physician indicates a “rule out”, he/she must also
include signs/symptoms prompting the exam for
the “rule out” condition.
14
8
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
What constitutes an order?
• An "order" is a communication from the
treating (referring) physician/practitioner
requesting that a diagnostic test be
performed for a beneficiary.
– Written document
– Telephone call
– Email
• May be conditional
15
Can a testing facility modify a test order
or perform additional tests?
• The treating (referring) 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.
• This policy is intended to prevent the practice of some
testing facilities to routinely apply protocols which require
performance of sequential tests.
16
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
9
EXHIBIT A
Can a testing facility modify a test order
or perform additional tests?
• Depending upon the site of service (hospital vs.
nonhospital), additional nonordered imaging
cannot be performed unless it falls into very
specific and explicit safe harbors.
– Medicare's Ordering of Diagnostic Tests rule
(Medicare Carriers Manual 15021, Transmittal 1725)
– The performance and coding of an additional limited
diagnostic ultrasound study clearly does not meet
those criteria in a nonhospital setting. In a hospital
setting, the answer is less clear, but a conservative
interpretation would indicate that this is problematic
as well.
Source: ACR Coding Source, Sept/Oct 2005
17
Are there any exceptions to the
rules?
• YES!
– 5 criteria for additional tests must be met
•
•
•
•
Test originally ordered is performed
Based on result additional diagnostic test is necessary
Delaying performance of test would have adverse effect
Result communicated to referring physician and used in
treatment of patient
• Interpreting physician documents why additional testing is
done
– Test design
– Clear error
– Patient condition
18
10
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
Radiology Report
Documentation Guidelines
19
ACR Practice Guidelines
for Communication
• “Effective communication is a critical component of
diagnostic imaging. Quality patient care can only be
achieved when study results are conveyed in a timely
fashion to those ultimately responsible for treatment
decisions.”
• “An official interpretation (final report) shall be generated
and archived following any examination, procedure, or
officially requested consultation regardless of the site of
performance (hospital, imaging center, physician office,
mobile unit, etc.)”
20
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
11
EXHIBIT A
ACR Practice Guidelines
for Communication
• Demographics
• Findings
• Clinical indications
• Limitations
• Description of
procedures
• Clinical issues
• Materials
• Impression
• Comparative Data
http://www.acr.org/s_acr/bin.asp?TrackID=&SID=1&DID=12196&CID=541&VID=2&DOC=
http://www.acr.org/s_acr/bin.asp?CID=539&DID=12267&DOC=FILE.PDF
21
CPT Coding & Documentation
Guidelines
22
12
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
Documentation Guidelines
• CPT-Specific Guidelines
– Carefully review the guidelines at the beginning
of each section in CPT.
– Know and adhere to the subsection- and codespecific guidelines & documentation
requirements.
– Utilize CPT Assistant references when
available/applicable.
23
US Documentation Guidelines CPT
• Permanently recorded images with
measurements, when such measurements are
clinically indicated.
• A final, written report
• Complete vs. limited
• To code complete – a description of elements or the reason
an element could not be visualized (eg, obscured by bowel
gas, surgically absent etc.).
• If less than the required elements for a "complete" exam are
reported (eg, limited number of organs or limited portion of
region evaluated), the "limited" code for that anatomic region
should be used once per patient exam session.
24
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
13
EXHIBIT A
US Documentation Guidelines
• Doppler evaluation of vascular structures is separately
reportable (other than color flow used only for anatomic
structure identification). 93875-93990
• Ultrasound guidance
– permanently recorded images of the site to be localized
– documented description of the localization process, either
separately or within the report of the procedure for which the
guidance is utilized.
• Use of ultrasound, without thorough evaluation of
organ(s) or anatomic region, image documentation, and
final, written report, is not separately reportable.
25
US Documentation Guidelines (cont.)
• For those anatomic regions that have "complete" and
"limited" ultrasound codes, note the elements that
comprise a "complete" exam. The report should contain
a description of these elements or the reason that an
element could not be visualized (eg, obscured by bowel
gas, surgically absent etc.).
• If less than the required elements for a "complete" exam
are reported (eg, limited number of organs or limited
portion of region evaluated), the "limited" code for that
anatomic region should be used once per patient
exam session. A "limited" exam of an anatomic region
should not be reported for the same exam session as a
"complete" exam of that same region.
26
14
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
Abdomen - Complete
•
•
•
•
•
•
•
•
Liver
Gall bladder
Common bile duct
Pancreas
Spleen
Kidneys
Upper abdominal aorta
Inferior vena cava
27
Limited US - Abdomen
• If an US is performed on 2 quadrants (LLQ
& RLQ) is it appropriate to bill 76705 twice?
Source: CPT Assistant, April 2003
28
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
15
EXHIBIT A
Retroperitoneum - Complete
•
•
•
•
•
Kidneys
Abdominal aorta
Common iliac artery origins
Inferior vena cava,
If clinical history suggests urinary tract
pathology include
– Kidneys
– Urinary bladder
29
Limited Retroperitoneum
• What code should be reported for US of
the bladder alone?
– Kidneys alone?
Source: CPT Assistant, May 1999
30
16
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
OB – 76801, 76802
First Trimester
• Determination of # of gestational sacs and
fetuses
• Gestational sac/fetal measurements appropriate
for gestation (<14 weeks 0 days)
– mean gestational sac size crown-rump length
• Survey of visible fetal and placental anatomic
structure
• Qualitative assessment of amniotic fluid
volume/gestational sac shape
• Examination of the maternal uterus and adnexa
31
Obstetrical
76805, 76810
•
•
Determination of number of fetuses and amniotic/chorionic sacs
Measurements appropriate for gestational age (> or = 14 weeks 0
days)
– Biparietal diameter head circumference
– Femur length
– Abdominal circumference
•
•
•
•
•
•
Survey of intracranial/spinal/abdominal anatomy
4 chambered heart
Umbilical cord insertion site
Placenta location
Amniotic fluid assessment
Examination of maternal adnexa (when visible)
Source: CPT Assistant March 2003
32
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
17
EXHIBIT A
Obstetrical
76811, 76812
• Performed for pregnancies at elevated risk of birth
defects
• All elements of 76085 & 76810 plus:
• Detailed anatomic evaluation of:
–
–
–
–
–
–
–
–
the fetal brain/ventricles
face
heart/outflow tracts and chest anatomy
abdominal organ specific anatomy
number/length/architecture of limbs
umbilical cord
placenta
other fetal anatomy as clinically indicated
Source: CPT Assistant March 2003
33
OB - 76815
• Use 76815 for a quick look of one or more
of elements in code
• Code 76815 per exam, not fetus
Source: CPT Assistant March 2003
34
18
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
OB -76816
• Reassessment of fetal size and interval
growth
• Re-evaluate anatomic abnormalities on a
previous US
• Code once per fetus
• Append modifier -59 for each additional
fetus
Source: CPT Assistant March 2003
35
Transabdominal US - 76856
• Includes the complete evaluation of the female pelvic anatomy.
– description and measurements of the uterus and adnexal
structures,
– measurement of the endometrium,
– measurement of the bladder (when applicable),
– a description of any pelvic pathology (eg, ovarian cysts,
uterine leiomyomata, free pelvic fluid).
• Applicable to a complete evaluation of the male pelvis.
– evaluation and measurement (when applicable) of the urinary
bladder
– evaluation of the prostate and seminal vesicles to the extent
that they are visualized transabdominally
– any pelvic pathology (eg, bladder tumor, enlarged prostate,
free pelvic fluid, pelvic abscess).
36
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
19
EXHIBIT A
Transabdominal & Transvaginal US
• If order states Pelvic US, and both
transabdominal and transvaginal are
performed can both be coded?
– If a T/A US does not yield an adequate
examination (i.e. ovaries and adnexa not
visualized due to superimposed distended
gas-filled loops of bowel) a T/V exam is
medically necessary to fully evaluate the
ovaries and adnexa
• Code the T/V study (76830) in addition to
the T/A study
37
What is a duplex scan?
• Combines Doppler and conventional
ultrasound
– Conventional US: view structure of blood
vessels
– Doppler US: view movement and speed of
blood through the vessels
• Duplex ultrasound produces images that
can be color coded to show physicians
where blood flow is blocked
38
20
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
US & Duplex – To Code or Not to
Code?
• Doppler studies should NOT be routinely
performed and billed in conjunction with US
• When it is medically necessary to perform a
vascular study in conjunction with ultrasound of
an organ, it is appropriate to report the vascular
study separately, however,
– to code a duplex study, true vascular analysis needs
to be performed.
– duplex should not be coded when color is just turned
on to determine if a structure is vascular
39
Ultrasound & Duplex
• NCCI edits allow -59 modifier
• Edits designed to prevent inappropriate use of
the noninvasive Doppler imaging codes
– when Doppler is performed with a real-time US study
for anatomical structure identification
– where an evaluation of blood flow is performed for a
valid medical reason in addition to gray scale
evaluation, billing of both CPT codes is justified.
Source: ACR Coding Source, Nov/Dec 2005
40
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
21
EXHIBIT A
Ultrasound & Duplex
• CMS does NOT consider US exams to be
components of duplex scans.
• The column 1 and column 2 coded procedures
are generally performed for different clinical
scenarios although there are some instances
where both procedures may be necessary.
Source: ACR Coding Source, Nov/Dec 2005
41
US & Duplex - Orders
• Documentation of an order from a
physician for both examinations should be
maintained.
– Hospital setting the ordering physician may be
the radiologist.
– An order from the referring physician is
required in the freestanding (nonhospital) and
IDTF setting.
Source: ACR Coding Source, Nov/Dec 2005
22
42
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
Ultrasound & Duplex
• The 20 code pairs requiring modifier -59:
93975 76700
93976 76700
93978 76770
93979 76770
93975 76705
93976 76705
93978 76775
93979 76775
93975 76770
93976 76770
93978 76986
93975 76775
93976 76775
93975 76856
93976 76778
93975 76778
93976 76986
93979 76856
93979 76986
93975 76986
Source: ACR Coding Source, Nov/Dec 2005
43
Ultrasound & Duplex (cont.)
PROCEDURE: US SCROTUM & CONTENTS
FINDINGS: Real-time imaging reveals the right testicle to measure 2.7
x 4.2 x 3.2 cm and show normal echo texture. The right epididymis
measures 1.0 cm and appears intact. Color flow Doppler imaging
demonstrates normal flow to the epididymis and testicle.
Real-time imaging reveals the left testicle to measure 2.5 x 4.3 x 3.1 cm
and demonstrates normal echo texture. The left epididymis
measures 1.4 cm and appears intact. Color flow Doppler imaging
demonstrates normal flow to the epididymis and testicle.
There is persistence of the small left varicocele which is unchanged
from the prior examinations of 11/08/04 and 04/09/04. A small left
hydroceles and benign appearing calcifications are stable.
What CPT code(s) should be assigned?
44
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
23
EXHIBIT A
Ultrasound Guidance
• Is the radiologist required to state in the
report "permanent images are stored"?
– Radiologist is required to dictate a statement
about the localization process, eg, ultrasound
guidance was used for needle placement,
NOT that permanent images are stored.
– “Permanent images" should be retrievable in
the event of a practice audit.
Source: ACR Coding Source, Jan/Feb 2005
45
Ultrasound Guidance
• CPT 2005 clearly states that permanent
images of the target area are required
when imaging guidance is utilized.
• Limited sonography of the target area is
included in imaging guidance codes.
Source: ACR Coding Source, Sept/Oct 2005
24
46
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
US w/ US Guidance
• Patient presents with an order for an USguided thoracentesis or paracentesis and
the technologist performs a limited US to
evaluate how much fluid (if any) is present
and in which location.
– Is it appropriate to charge a limited diagnostic
US in addition to the guidance and procedure
code?
Source: ACR Coding Source, Sept/Oct 2005
47
US Guidance – Vascular Access
• CPT code 76937 specifically lists the
requirements for using this code:
– ultrasound evaluation of the potential access
sites
– documentation of selected vessel patency
– concurrent real-time ultrasound visualization
of vascular needle entry
– permanent recording and reporting.
48
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
25
EXHIBIT A
CT vs. CTA
• Computed tomographic angiography is a less
invasive technique for imaging vessels that has
gained widespread use in clinical practice. The
information obtained from the CTA is used in the
evaluation of vascular anatomy
• Imaging of the vessels is not necessarily a CTA.
The key distinction between CTA and CT is that
CTA includes reconstruction post-processing of
angiographic images and interpretation. If
reconstruction postprocessing is not done, it is
not a CTA study.
Source – AMA CPT Assistant, Volume 11, Issue 7, July 2001
49
CT vs. CTA
• Injection of contrast material is part of the “with contrast”
CTA procedure; it is not appropriate to separately report
the code for the administration of contrast
• The supply of contrast may be reported separately with
CPT code 99070 or with the appropriate HCPCS Level II
code for the contrast material used
• Typically a noncontrast sequence(s) is performed for
localization; this is indicated in the “ without” component
of the CTA code and is not separately reported
• Evaluation of source images is an inclusive component
of the CTA interpretation
• Administration of oral and/or rectal contrast alone does
not qualify as a study “with contrast” and are not typically
used in CTA since they tend to obscure the vasculature.
Source – AMA CPT Assistant, Volume 11, Issue 7, July 2001
50
26
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
CT vs. CTA (cont.)
• Patient presents with hip fracture and
shortness of breath; evaluate artery for
possible pulmonary embolism.
– A contrast enhanced CT of the chest is
performed and tailored to evaluate the
pulmonary arterial circulation for presence of
pulmonary emboli. No angiographic
reformatted images are obtained.
– Is this a CT or a CTA?
Source – AMA CPT Assistant, Volume 11, Issue 7, July 2001
51
CT vs. CTA (cont.)
• This example illustrates a contrast
enhanced CT of the chest rather than a
CTA, and should be reported as 71260.
Source – AMA CPT Assistant, Volume 11, Issue 7, July 2001
52
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
27
EXHIBIT A
Coronary CT and CTA
• ACR, ACC, and BCBS worked together to create several
new Category III CPT codes for 2006 describing various
common combinations of cardiac CT and CTA studies
• This structure allows, in most cases, for a single code to
describe the combination of services performed.
• For more information on these and other Category III
codes, see http://www.amaassn.org/ama/pub/category/3885.html
53
Coronary CT and CTA (cont.)
• Eight new Category III codes have been
created to report cardiac CT and CTA for:
– Coronary calcium evaluation (“calcium
scoring”)
– Coronary CTA (CT Coronary Angiography)
– CT evaluation of cardiac structure,
morphology, function and vasculature
54
28
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
Coronary CT and CTA (cont.)
• As of January 1, 2006, the Category III
codes must be used to report these
studies since they accurately describe the
procedure performed.
• This is both a CPT and a HIPAA
Requirement!
http://www.cms.hhs.gov/hipaa/hipaa2/regulations/transactio
ns/default.asp
http://www.hipaadvisory.com/action/Compliance/TransCodeSetsGuide.htm
55
Coronary CT and CTA (cont.)
• Cardiac Computed Tomography (CT) and
Computed Tomographic Angiography
(CTA)
– See Category III Codes 0144T – 0150T (and
add-on code 0151T) to report various types of
cardiac CT and CTA examinations
– Report the appropriate code(s) based on
whether coronary CT, CTA and/or calcium
scoring is performed
– If function evaluation is performed (left & right
ventricular function, ejection fraction, and
segmental wall motion), report add-on code
0151T
Do not separately report 3D rendering
56
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
29
EXHIBIT A
3D Rendering – 76376/76377
• 76375 Deleted for 2006
• 2D no longer separately billable
– Coronal
– Sagittal
– Multiplanar
– Oblique reformats
from 2D axial images
Source: Clinical Examples in Radiology, Volume 2, Issue 1: Winter 2006
57
3D Rendering – 76376 / 76377 (cont.)
•
76376 3D rendering with interpretation and reporting of computed
tomography, magnetic resonance imaging, ultrasound, or other
tomographic modality; not requiring image post-processing on an
independent workstation
•
76377 3D rendering with interpretation and reporting of computed
tomography, magnetic resonance imaging, ultrasound, or other
tomographic modality; requiring image post-processing on an
independent workstation
•
Require concurrent physician supervision of image post processing
3D manipulation of volumetric data set and image rendering
•
Should not be reported in conjunction with CTA, MRA, PET, CT
colonography, nuclear medicine codes or the Category III cardiac
CT/CTA codes.
58
30
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
3D Rendering – 76376 / 76377 (cont.)
• New codes represent complex renderings:
– Shaded surface
– Volumetric rendering
– Quantitative analysis (segmental volumes and surgical
planning)
– Maximum Intensity Projections (MIP)
• Performed on scanner or independent workstation
Source: Clinical Examples in Radiology, Volume 2, Issue 1: Winter 2006
59
3D Rendering – 76376/76377 (cont.)
• Method of reformatting
• Physician Supervision
– What does “concurrent” mean?
– What does Medicare require?
• Required documentation
– Test order
• Do I need an order from the referring doctor to bill for 3D
rendering?
– Radiology Report
• Must the radiology report state “3D images acquired” or “3D
images acquired on independent workstation”?
Source: Clinical Examples in Radiology, Volume 2, Issue 1: Winter 2006
60
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
31
EXHIBIT A
Contrast Materials
• “With contrast" refers to contrast administered:
– Intravascularly
– Intra-articularly
– Intrathecally
• Injection of IV contrast is part of the "with contrast" - CT,
CTA, MRI, and MRA procedures.
– For intra-articular injection, use the appropriate joint
injection code.
– For spine examinations "with contrast" includes
intrathecal or intravascular injection. For intrathecal
injection, use also 61055 or 62284
• Oral and/or rectal contrast administration alone does not
qualify as a study "with contrast."
61
Contrast Coding & Documentation
•
•
•
•
•
Route of administration
Type
Concentration
Amount
Injecting the material is “bundled”,
however the appropriate HCPCS code
should be assigned for the contrast
62
32
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
Supervision and Interpretation
• Radiological supervision and
interpretation (RS&I) codes require just
that – both supervision and interpretation
by the radiologist
• If either supervision or interpretation is not
performed, append a modifier -52 to the
RS&I code
63
PET & PET/CT
• We have a PET/CT Integrated System and
the referring physician’s initial order states
PET study. Can we perform and bill a
PET/CT?
Source: SNM Comments/Guidelines for PET/CT with Integrated Systems, July 2005
64
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
33
EXHIBIT A
PET & PET/CT (cont.)
• We have a PET/CT Integrated System. A
referring physician has ordered a
diagnostic CT & a PET/CT for anatomic
localization on the same day. Our current
PET/CT integrated system is capable of
performing diagnostic CTs. How are these
studies coded?
Source: SNM Comments/Guidelines for PET/CT with Integrated Systems, July 2005
65
PET & PET/CT (cont.)
• If a PET/CT and a diagnostic CT are
performed on the same day, how are
these studies coded?
Source: ACR Coding Source, July/Aug 2005
34
66
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
PET & PET/CT (cont.)
• Who can make the determination that a
PET/CT and a diagnostic CT are required?
Source: ACR Coding Source, July/Aug 2005
67
PET & PET/CT (cont.)
• We have a PET only system, but we
acquire a CT for fusion following the PET
scan. Can we use the PET/CT CPT codes
78814-78816?
Source: SNM Comments/Guidelines for PET/CT with Integrated Systems, July 2005
68
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
35
EXHIBIT A
PET & PET/CT (cont.)
• Additionally, we are fusing PET scans with
both CT and MRI studies NOT acquired
concurrently with integrated systems, how
do we code for these studies including the
fused images?
Source: SNM Comments/Guidelines for PET/CT with Integrated Systems, July 2005
69
PET & PET/CT (cont.)
• Can I report 3D rendering in addition to a
PET and PET/CT for anatomic localization
procedure if the report documents this was
completed?
• Do I code and bill separately using CPT or
HCPCS Level II codes for the PET
radiopharmaceuticals?
Source: SNM Comments/Guidelines for PET/CT with Integrated Systems, July 2005
70
36
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
Mammography Test Orders
• Screening Mammography
– Performed on an asymptomatic female
– At a minimum CC & MLO views are obtained of each
breast.
• Diagnostic Mammography
– called problem-solving mammography or consultative
mammography.
– Performed because there is a reasonable suspicion
that an abnormality may exist in the breast
– Additional views performed for diagnostic
mammography
The patient’s physician determines which type of exam is appropriate.
71
Post Procedure Mammograms
• Is it appropriate to code for a mammogram
following a vacuum-assisted, imageguided biopsy and tissue marker
placement?
– Depends on the modality used
– Depends on the number of physicians
involved
72
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
37
EXHIBIT A
Outpatient Coding Guidelines
73
Coding Guidelines
• Use the ICD-9-CM code that describes the patient’s
diagnosis, symptom, compliant, condition, or problem.
Do not code a suspected diagnosis.
• Use the ICD-9-CM code that is chiefly responsible for
the item or service provided.
• Assign codes to the highest level of specificity.
• Code chronic conditions when they apply to the patients
treatment and code all documented conditions that
affect treatment at the visit.
• Do not code conditions that no longer exist.
74
38
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
Coding Guidelines (cont.)
• Most of the time Medicare utilizes the primary ICD-9
code to make a medical necessity determination
• Use the following guidelines to assign the primary
diagnosis code
– Code a diagnosis confirmed by test results
– Code signs/symptoms when findings are normal or when the
findings are uncertain (ie. Probable, suspected,
questionable)
– Do not code incidental findings or unrelated co-existing
conditions
– For screening tests (those performed in the absence of
signs/symptoms) assign the appropriate V code (findings are
coded as secondary)
75
Coding FAQs
• Can I code from the header of the radiology
report?
– Must the body of the report support the exam
stated in the header?
• If a radiologist uses the phrase “consistent
with” in his report can I code the condition
as a definitive diagnosis?
– Coding Clinic, 3rd Quarter 2005
76
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
39
EXHIBIT A
“Pecking” Order for ICD-9 Coding
• Radiology Report
– Findings
– Indications
• Test orders
77
Medical Necessity
78
40
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
What is medical necessity?
• Medicare defines medical necessity as a
determination of a service that is
reasonable and necessary for the
diagnosis of illness or injury.
– Medicare covers only those services that are
reasonable and necessary
– Medicare requires all providers to report
information regarding the patient’s diagnosis
when seeking payment to determine whether
services ordered were medically necessary.
79
Covered vs. Non-Covered Services
Non-Covered:
•
•
•
Never covered by a third party regardless of diagnosis or
circumstances.
Medicare documents non-covered services in Section 1862 of the
Social Security Act.
Other third party payers make individual determinations on which
services are non-covered.
Covered:
•
•
•
May be either preventative or diagnostic.
Can be either medically necessary or not medically necessary.
Payers provide written coverage guidelines for specific procedures,
usually in the form of Local Medical Review Policies, to determine
whether or not services are medically necessary.
80
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
41
EXHIBIT A
Performing a Medical Necessity
Check
• Determine whether the test/service has an NCD or
LCD
• If the test/service does not have limited coverage
under NCD or LCD proceed with test
• If test/service does have limited coverage under NCD
or LCD, review the signs/symptoms or diagnosis that
prompted the test to be ordered
• If the test/service provided does not meet medical
necessity requirements and/or the s/s or dx is not on
the list of covered ICD-9 codes, complete an ABN
• For those tests with frequency limitations, review the
appropriate section of the coverage determination
and obtain an ABN when frequency is exceeded.
81
Advance Beneficiary Notice
CMS has published two official ABNs:
• CMS-R-131-G—use this for any services,
including lab services.
– This form can be customized in the “Items or Services”
and
“Because” boxes, and in the header.
• CMS-R-131-L—use this only for lab services,
usually at a freestanding diagnostic laboratory
testing facility.
– This form can be customized in the header and in the
“Reasons and Tests” three- column box area.
82
42
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
Improving Physician
Documentation
83
Working With Physicians
•
What do they need to know?
- Documentation guidelines per CPT and ACR
•
Standard Complaints
- “Documentation takes time away from patient care”
- “Compliance and correct coding do not contribute to
the quality of patient care”
These statements are NOT TRUE!
Good documentation is critically important to patient care.
84
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
43
EXHIBIT A
Working With Physicians (cont.)
• Identify a physician “champion” to assist in physician
education
- Physicians are more likely to consider messages coming from
another physician
• Identify and address documentation errors right away
- Timely discussion facilitates front-end correct claims and instills a
sense of urgency and importance
• Differentiate between “clinical speak” and “code speak”
- Educate as to what coders need in order to make distinctions
between medical terms (e.g. sepsis and urosepsis)
Source: HCPro’s Briefings on Coding and Compliance Strategies, February 2002
85
Working With Physicians (cont.)
• Address doctors directly
- Look them in the eye
- Offer privacy and convenience
- Keep them involved: Welcome physicians’ input and let
them know it is valuable
- Never react back
- Don’t be intimidated!
• Make an Impression
– Just the facts
Personal responsibility/liability
Financial impact (money talks!)
86
44
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT A
Working With Physicians (cont.)
• Nothing has worked – Now What?
- Disciplinary action
Develop an improvement tool (such as a
form) to document issues areas of concern
Form should be completed and submitted to
disciplinary committee (medical director, chief
radiologist, physician champion) for review and
discussion of possible resolution
87
For additional information visit:
http://www.seradmgt.com/CodingReimbursement.html
•
•
•
•
•
SNM FAQ’s
Modifier -59
Diagnostic Test Order FAQs
ICD-9 Coding for Diagnostic Tests
Mammography Test Order Criteria
http://www.seradmgt.com/internet.html
• ACR Guidelines for Diagnostic Communication
• Medicare Claims Processing Manual
88
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
45
EXHIBIT A
Q&A
Stacie Buck
Email: stacie@southeastrad.com
Stacy Gregory
Email: stacygregory@wamail.net
89
46
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
Exhibit B
Medicare’s Requirements for Ordering Diagnostic Tests
Source: Stacie L. Buck, RHIA, LHRM. Reprinted with permission.
EXHIBIT B
Southeast Radiology Management
Management Ⱦ Billing Ⱦ Compliance Ⱦ Audits
www.seradmgt.com
Medicare’s Requirements for Ordering Diagnostic Tests
Does the referring physician need to include signs/symptoms or a diagnosis?
Yes, section 4317(b) of the Balanced Budget Act (BBA), requires referring physicians to provide this diagnostic
information to the testing entity at the time the test is ordered. If the referring physician indicates a “rule out”,
he/she must also include signs/symptoms prompting the exam for the “rule out” condition.
What constitutes an order?
An "order" is a communication from the treating (referring) physician/practitioner requesting that a diagnostic test
be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular
beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating
physician/practitioner (e.g., if test X is negative, then perform test Y).
An order may include the following forms of communication:
i
i
i
A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or
faxed to the testing facility;
A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
An electronic mail by the treating physician/practitioner or his/her office to the testing facility.
If the order is communicated via telephone, both the treating (referring) physician/practitioner or his/her office,
and the testing facility must document the telephone call in their respective copies of the beneficiary's medical
records.
The treating (referring) 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. This policy is intended to prevent the practice of some testing facilities to routinely apply protocols which
require performance of sequential tests.
When the testing facility or radiologist determines that an ordered diagnostic test is clinically inappropriate
or suboptimal and that a different diagnostic test (e.g. MRI instead of CT) should be performed, can the
testing facility or radiologist modify the order?
No, the interpreting physician/testing facility may not perform the unordered test until a new order from the
treating physician/practitioner has been received.
What happens when the results of an ordered diagnostic test are normal and the interpreting physician
believes that another diagnostic test should be performed (e.g., a renal sonogram was normal and based on
the clinical indication, the interpreting physician believes an MRI will reveal the diagnosis)?
An order from the treating physician must be received prior to performing the unordered diagnostic test.
Are there any exceptions to the rules for modifying test orders?
Yes, there are four exceptions to the rules. These exceptions apply to an interpreting physician of a testing
facility who furnishes a diagnostic test to a beneficiary who is not a hospital inpatient or outpatient. The
interpreting physician must document accordingly in his/her report to the treating physician/practitioner.
Created by:
Stacie L. Buck, RHIA, LHRM
Vice President, Southeast Radiology Management
48
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT B
Southeast Radiology Management
Management Ⱦ Billing Ⱦ Compliance Ⱦ Audits
www.seradmgt.com
The first exception concerns additional testing. If the testing facility cannot reach the treating
physician/practitioner to change the order or obtain a new order and documents this in the medical record, then
the testing facility may furnish the additional diagnostic test if all of the following criteria apply:
i
i
i
i
i
The testing center performs the diagnostic test ordered by the treating physician/practitioner;
The interpreting physician at the testing facility determines and documents that, because of the
abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary;
Delaying the performance of the additional diagnostic test would have an adverse effect on the
care of the beneficiary;
The result of the test is communicated to and is used by the treating physician/practitioner in the
treatment of the beneficiary; and
The interpreting physician at the testing facility documents in his/her report why additional testing was
done.
Examples:
i
i
The last cut of an abdominal CT scan with contrast shows a mass requiring a pelvic CT scan to
further delineate the mass;
A bone scan reveals a lesion on the femur requiring plain films to make a diagnosis.
The second exception applies to test design. 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
The third exception is clear error. The interpreting physician may modify, without notifying the treating
physician/practitioner, an order with clear and obvious errors that would be apparent to a reasonable layperson,
such as the patient receiving the test (e.g., x-ray of wrong foot ordered).
The fourth exception is patient condition. The interpreting physician may cancel, without notifying the treating
physician/practitioner, an order because the beneficiary's physical condition at the time of diagnostic testing will
not permit performance of the test (e.g., a barium enema cannot be performed because of residual stool in colon
on scout KUB; PA/LAT of the chest cannot be performed because the patient is unable to stand). When an ordered
diagnostic test is cancelled, any medically necessary preliminary or scout testing performed is payable.
Created by:
Stacie L. Buck, RHIA, LHRM
Vice President, Southeast Radiology Management
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
49
Exhibit C
Incomplete Test Orders Tracking Sheet
Source: Stacie L. Buck, RHIA, LHRM. Reprinted with permission.
EXHIBIT C
Incomplete Test Orders Tracking Sheet
This form should be completed in the event that a patient arrives with a prescription without
required diagnostic information (i.e. signs/symptoms, narrative diagnosis, or ICD-9 code), or a
prescription that states “rule out” with no presenting signs/symptoms.
The referring physician office must be contacted for the required diagnostic information.
THIS FORM IS NOT TO BE USED TO TAKE VERBAL ORDERS FOR TESTING. All tests should be ordered in
writing directly from the referring physician.
Testing Information
Patient Name:
Referring Physician:
Date of Exam:
Type of Exam:
Phone Call Log
Date & Time of Call:
Name of person providing information:
Signs/Symptoms or Diagnosis:
Other information required: __________________________________
When contacting the referring physician, ask to have a new prescription faxed over that contains all
required information.
Notes:
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
51
Exhibit D
ICD-9-CM Coding Requirements for Diagnostic Tests
Source: Stacie L. Buck, RHIA, LHRM. Reprinted with permission.
EXHIBIT D
Southeast Radiology Management
Management Ⱦ Billing Ⱦ Compliance Ⱦ Audits
www.seradmgt.com
ICD-9-CM Coding Requirements for Diagnostic Tests
CMS requires following the ICD-9-CM Coding Guidelines for Outpatient Services (hospital-based
and physician office). These guidelines instruct physicians to report diagnoses based on test
results, if available. Health care providers must comply with the following instructions in
determining the appropriate ICD-9-CM diagnoses code for diagnostic test results. These
instructions simplify coding for diagnostic tests consistent with the ICD-9-CM Guidelines for
Outpatient Services (hospital-based and physician office).
General rules for reporting diagnosis codes on the claim are:
i Use the ICD-9-CM code that describes the patient’s diagnosis, symptom, complaint,
condition or problem. Do not code suspected diagnosis.
i Use the ICD-9-CM code that is chiefly responsible for the item or service provided.
i Assign codes to the highest level of specificity. Use the fourth and fifth digits where
applicable.
i Code a chronic condition as often as applicable to the patient’s treatment.
i Code all documented conditions that coexist at the time of the visit that require or
affect patient care or treatment. (Do not code conditions that no longer exist.)
Determining the Appropriate Primary ICD-9-CM Diagnosis Code for Diagnostic Tests Ordered
Due to Signs and/or Symptoms
Confirmed Diagnosis Based on Results of Test
If the physician has confirmed a diagnosis based on the results of the diagnostic test, the
physician interpreting the test should code that diagnosis. The signs and/or symptoms that
prompted ordering the test may be reported as additional diagnoses if they are not fully
explained or related to the confirmed diagnosis.
Example: A patient is referred to a radiologist for an abdominal CT scan with a diagnosis of
abdominal pain. The CT scan reveals the presence of an abscess. The radiologist should report a
diagnosis of “intra-abdominal abscess.”
If the individual responsible for reporting the codes for the testing facility or the physician’s
office does not have the report of the physician interpretation at the time of billing, the
individual responsible for reporting the codes for the testing facility or the physician’s office
should code what they know at the time of billing. Sometimes reports of the physician’s
interpretation of diagnostic tests may not be available until several days later, which could
result in delay of billing. Therefore, in such instances, the individual responsible for reporting
Created by:
Stacie L. Buck, RHIA, LHRM
Vice President, Southeast Radiology Management
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
53
EXHIBIT D
Southeast Radiology Management
Management Ⱦ Billing Ⱦ Compliance Ⱦ Audits
www.seradmgt.com
the codes for the testing facility or the physician’s office should code based on the information/
reports available to them, or what they know, at the time of billing.
Signs or Symptoms
If the diagnostic test did not provide a diagnosis or was normal, the interpreting physician should
code the sign(s) or symptom(s) that prompted the treating physician to order the study.
Example: A patient is referred to a radiologist for a spine x-ray due to complaints of “back
pain.” The radiologist performs the x-ray, and the results are normal. The radiologist should
report a diagnosis of “back pain” since this was the reason for performing the spine x-ray.
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. However, an attempt should be made to confirm any information
obtained from the patient by contacting the referring physician.
Example: A patient is referred to a radiologist for a gastrograffin enema to rule out
appendicitis. However, the referring physician does not provide the reason for the referral and is
unavailable at the time of the study. The patient is queried, indicates that he/she saw the
physician for abdominal pain, and was referred to rule out appendicitis. The radiologist performs
the x-ray, and the results are normal. The radiologist should report the abdominal pain as the
primary diagnosis.
If the physician’s interpretation of the test result is not clear or is ambiguously stated in the
patient’s medical record, either the attending physician or the physician that performed that
test should be contacted for clarification. This may result in the reporting of symptoms or a
confirmed diagnosis.
Diagnosis Preceded by Words that Indicate Uncertainty
If the results of the diagnostic test are normal or nondiagnostic and the referring physician
records a diagnosis preceded by words that indicate uncertainty (e.g., probably, suspected,
questionable, rule out, or working), then the interpreting physician should not code the
referring diagnosis. Rather the interpreting physician should report the sign(s) or symptom(s)
that prompted the study. Diagnoses labeled as uncertain are considered by the ICD-9-CM Coding
Guidelines as unconfirmed and should not be reported. This is consistent with the requirement
to code the diagnosis to the highest degree of certainty.
Created by:
Stacie L. Buck, RHIA, LHRM
Vice President, Southeast Radiology Management
54
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
EXHIBIT D
Southeast Radiology Management
Management Ⱦ Billing Ⱦ Compliance Ⱦ Audits
www.seradmgt.com
Example: A patient is referred to a radiologist for a chest x-ray with a diagnosis of “rule out
pneumonia.” The radiologist performs a chest x-ray, and the results are normal. The radiologist
should report the sign(s) or symptom(s) that prompted the test (e.g., cough).
Incidental Findings
Incidental findings should never be listed as primary diagnoses. If reported, incidental findings
may be reported as secondary diagnoses by the physician interpreting the diagnostic test.
Example: A patient is referred to a radiologist for an abdominal ultrasound due to jaundice.
After review of the ultrasound, the interpreting physician discovers that the patient has an
aortic aneurysm. The interpreting physician reports jaundice as the primary diagnosis and may
report the aortic aneurysm as a secondary diagnosis because it is an incidental finding.
Example: A patient is referred to a radiologist for a chest x-ray because of wheezing. The x-ray
is normal except for scoliosis and degenerative joint disease of the thoracic spine. The
interpreting physician reports wheezing as the primary diagnosis since it was the reason for the
patient’s visit and may report the other findings (scoliosis and degenerative joint disease of the
thoracic spine) as additional diagnoses.
Unrelated Coexisting Conditions/Diagnoses
Unrelated and coexisting conditions/diagnoses may be reported as additional diagnoses by the
physician interpreting the diagnostic test.
Example: A patient is referred to a radiologist for a chest x-ray because of a cough. The result
of the chest x-ray indicates the patient has pneumonia. During the performance of the
diagnostic test, it was determined that the patient has hypertension and diabetes mellitus. The
interpreting physician reports a primary diagnosis of pneumonia. The interpreting physician may
report the hypertension and diabetes mellitus as secondary diagnoses.
Diagnostic Tests Ordered in the Absence of Signs and/or Symptoms
When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness
or injury, the testing facility or the physician interpreting the diagnostic test should report the
screening code as the primary diagnosis code. Any condition discovered during the screening
should be reported as a secondary diagnosis.
Example: A patient is referred to a radiologist for a chest x-ray as part of a routine physical.
The result of the chest x-ray indicates a lung mass. The interpreting physician reports the
appropriate screening code as the primary diagnosis and reports the lung mass as a secondary
diagnosis.
Created by:
Stacie L. Buck, RHIA, LHRM
Vice President, Southeast Radiology Management
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
55
Exhibit E
Ordering Mammograms: Screening vs. Diagnostic
Source: Stacie L. Buck, RHIA, LHRM. Reprinted with permission.
EXHIBIT E
Southeast Radiology Management
Management Ⱦ Billing Ⱦ Compliance Ⱦ Audits
www.seradmgt.com
Ordering Mammograms: Screening vs. Diagnostic
Screening Mammography
Screening mammography is performed on an asymptomatic female that has not manifested any clinical
signs, symptoms, or physical findings of breast cancer. CC & MLO views are obtained of each breast.
9
If the patient is currently asymptomatic, most likely a screening mammogram is clinically appropriate.
Effective July 1, 2005 V76.11 is approved for use for submitting claims to Medicare for screening
mammograms.
CMS considers the following patients to be high risk:
x Has a personal history of breast cancer (V10.3)
x Has a family history of breast cancer - a mother, sister, or daughter who has breast cancer
(V16.3)
x Had her first baby after age 30 (V15.89)
x Has never had a baby. (V15.89)
9
If the patient meets one or more of the criteria above, please indicate V76.11, “Special screening for
malignant neoplasm, screening mammogram for high-risk patient” on the order for a screening
mammogram, plus the appropriate V-code noted above.
9
If the patient does not meet any of the criteria above, please indicate V76.12, “Special screening for
malignant neoplasm, other screening mammography” on the order for a screening mammogram.
Diagnostic Mammography
Diagnostic mammography is also called problem-solving mammography or consultative mammography. A
diagnostic mammogram is performed because there is a reasonable suspicion that an abnormality may
exist in the breast. Additional views are performed for a diagnostic mammogram.
Diagnostic mammograms are clinically appropriate under the following circumstances:
x Clinical signs, symptoms, or physical findings suggestive of breast cancer.
x An abnormal or questionable screening mammogram.
x A personal history of breast cancer.
x A personal history of biopsy-proven benign breast disease.
x A woman is asymptomatic, but based on her history and other factors the physician
considers significant, the physician’s judgment is that a diagnostic mammogram is
appropriate
9
If the patient meets one or more of the above conditions, request a diagnostic mammogram with the
appropriate indications documented on the order.
Created by:
Stacie L. Buck, RHIA, LHRM
Vice President, Southeast Radiology Management
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
57
Exhibit F
Modifier -59 Decision Tree
Source: Stacie L. Buck, RHIA, LHRM. Reprinted with permission.
Radiology Orders for Diagnostic Testing: Appropriate documentation for proper reimbursement
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