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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

The Treasure Hunt—Keys to Unlocking Radiology Reimbursement PAYMENT

Walt Blackham, MS, RCC

Radiology Business Management Association, RBMA

the role of coding
THE ROLE OF CODING

Communication between

  • You, the healthcare provider)

and the

  • Payer
    • The Patient
    • The insurance Company
    • Some other third party
the role of coding4
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 coding5
THE ROLE OF CODING
  • Coding is a unique language
the role of coding6
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 coding7
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 coding8
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 coding9
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
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
Level II HCPCS
  • Medicare alphanumeric codes for;
    • Procedures e.g. digital mammography
    • Non-Ionic Contrast
    • Radiopharmaceuticals
    • Other drugs and codeable supplies
the role of coding12
THE ROLE OF CODING

ICD-9-CM

  • Diagnosis codes describe why you did the particular CPT code
the role of coding13
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 coding14
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 coding15
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 coding16
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 coding17
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 coding18
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 coding19
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
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 model21
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 model22
DOCUMENTATION MODEL
  • Time of Exam Where Appropriate
    • Multiple portable chests on the same

day

documentation model23
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 model24
DOCUMENTATION MODEL
  • Body of Report
  • Impression or Conclusion
    • Except if report is very brief
  • Rendering radiologist’s name
the radiology report
The Radiology Report
  • If you can’t read it, you can’t code it.
questions
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

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