The treasure hunt keys to unlocking radiology reimbursement payment
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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

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The treasure hunt keys to unlocking radiology reimbursement payment l.jpg

The Treasure Hunt—Keys to Unlocking Radiology Reimbursement PAYMENT

Walt Blackham, MS, RCC

Radiology Business Management Association, RBMA


The role of coding l.jpg
THE ROLE OF CODING Reimbursement PAYMENT

Communication between

  • You, the healthcare provider)

    and the

  • Payer

    • The Patient

    • The insurance Company

    • Some other third party


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Correct Coding: Why Bother? Reimbursement PAYMENT


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THE ROLE OF CODING Reimbursement PAYMENT

  • 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 Reimbursement PAYMENT

  • Coding is a unique language


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THE ROLE OF CODING Reimbursement PAYMENT

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 Reimbursement PAYMENT

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 Reimbursement PAYMENT

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 Reimbursement PAYMENT

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 Reimbursement PAYMENT

  • 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 Reimbursement PAYMENT

  • 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 Reimbursement PAYMENT

ICD-9-CM

  • Diagnosis codes describe why you did the particular CPT code


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THE ROLE OF CODING Reimbursement PAYMENT

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 Reimbursement PAYMENT

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 Reimbursement PAYMENT

  • 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 Reimbursement PAYMENT

  • 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 Reimbursement PAYMENT

  • 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 Reimbursement PAYMENT

  • “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 Reimbursement PAYMENT

“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.”


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DOCUMENTATION MODEL Reimbursement PAYMENT

  • 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 Reimbursement PAYMENT

  • 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 Reimbursement PAYMENT

  • Time of Exam Where Appropriate

    • Multiple portable chests on the same

      day


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DOCUMENTATION MODEL Reimbursement PAYMENT

  • 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 Reimbursement PAYMENT

  • Body of Report

  • Impression or Conclusion

    • Except if report is very brief

  • Rendering radiologist’s name


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The Radiology Report Reimbursement PAYMENT

  • If you can’t read it, you can’t code it.


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Questions? Reimbursement PAYMENT

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


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