The Treasure Hunt

1
The Treasure HuntKeys to Unlocking Radiology
Reimbursement PAYMENT

• Walt Blackham, MS, RCC
• Radiology Business Management Association, RBMA

2
THE ROLE OF CODING

• Communication between
• You, the healthcare provider)
• and the
• Payer
• The Patient
• The insurance Company
• Some other third party

3
Correct Coding Why Bother?
4
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

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THE ROLE OF CODING

• Coding is a unique language

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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

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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.

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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

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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.

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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)

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Level II HCPCS

• Medicare alphanumeric codes for
• Procedures e.g. digital mammography
• Non-Ionic Contrast
• Radiopharmaceuticals
• Other drugs and codeable supplies

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THE ROLE OF CODING

• ICD-9-CM
• Diagnosis codes describe why you did the
  particular CPT code

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THE ROLE OF CODING

• ICD-9-CM
• 3 to 5 digit alphanumeric codes
• 001.0 through 999.9
• V01.0 through V86.1

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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

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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.

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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.

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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.

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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

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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
  patients medical record if it is available.

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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.

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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

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DOCUMENTATION MODEL

• Time of Exam Where Appropriate
• Multiple portable chests on the same
• day

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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.

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DOCUMENTATION MODEL

• Body of Report
• Impression or Conclusion
• Except if report is very brief
• Rendering radiologists name

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The Radiology Report

• If you cant read it, you cant code it.

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Questions?

• Walter C. Blackham, MS, RCC
• President and CEO
• Specialty Medical Services, Inc.
• 221 West 8th Street
• Lorain, OH 44052-1817
• Walt_at_SPMEDS.com
• 440.245.8010 Ext. 10