AHRA Provides Contrast Coding Pointers, -59 Modifier Caveat
The Bill Box
HIMSS Analytics Launches State Health Care Reports

AHRA Provides Contrast Coding Pointers, -59 Modifier Caveat

The American Healthcare Radiology Administrators (AHRA), Sudbury, Mass, recently offered an audio Web conference to update members on changes to radiology coding and impact on reimbursement. John Marshall, CRA, RCC, RT(R), a radiology consultant with Coding Strategies Inc, Powder Springs, Ga, covered new billable procedures, reimbursement, and what might be in store for 2007. He finished his presentation by looking at contrast and radiopharmaceuticals as well as contiguous body sections.

Marshall stressed that when injecting low osmolar contrast material (LOCM), total cost volume is charged. In other words, if one uses 73 mL of a 100 mL bottle, one should still charge for 100 units. He reiterated that units are measured per milliliter, not per bottle. The codes and reimbursements for LOCM are as follows:

  • Q9945: up to 149 mg/mL iodine, per mL—$0.294/mL
  • Q9946: 150 to 199 mg/mL iodine, per mL—$1.827/mL
  • Q9947: 200 to 249 mg/mL iodine, per mL—$1.243/mL
  • Q9948: 250 to 299 mg/mL iodine, per mL—$0.319/mL
  • Q9949: 300 to 349 mg/mL iodine, per mL—$0.364/mL
  • Q9950: 350 to 399 mg/mL iodine, per mL—$0.233/mL

Moving on to magnetic resonance contrast material, or gadolinium, he said, “I want to warn people that there seems to be a misnomer out there. Gadolinium is reimbursed on the hospital side. On the imaging center side, gadolinium is paid for the third dose.” He explained that when an imaging center uses gadolinium, the first dose is considered bundled into the procedures. On the other hand, he said, although most people consider high osmolar contrast media (HOCM) to be bundled, there will be reimbursements starting January 6. The codes and reimbursements for HOCM are as follows:

  • Q9952: gadolinium-based MR contrast agent, per mL—$2.81/mL
  • Q9954: oral MR contrast agent,per 100 mL—$8.978/mL
  • Q9958: up to 149 mg/mL—$0.06/mL
  • Q9960: 200 to 249 mg/mL—$.09/mL
  • Q9961: 250 to 299 mg/mL—$0.15/mL
  • Q9963: 350 to 399 mg/mL—$0.15/mL
  • Q9964: more than 400 mg/mL—$0.20/mL

Marshall touched on the new multiple procedure payment reduction. “It is here to stay. We’ll have to see what they do with this for next year; but right now, for any contiguous body parts within 11 separate families of codes, they pay the highest price in that code.” The highest-priced procedure is reimbursed 100%, and subsequent procedures in the same family are reimbursed 75%; discounts do not apply across families of codes.

He also injected a word of warning about the -59 modifier: “The circumstances under which that would be medically necessary are obscure. Basically, a patient comes one day and has a procedure for a medically necessary reason. The patient leaves, but then for some reason, something else happens and the patient comes back to you again. You do another procedure in that family on the same day, but it’s for a different medical reason.” CMS considers these to be multiple studies in the same family on the same day to be provided in separate sessions.

—C. Vasko

The Bill Box

Bill to Delay Imaging Cuts Introduced in House

On June 30, Rep Joe Pitts (R-Pa) introduced legislation to the House of Representatives that would delay for 2 years the cuts to medical-imaging reimbursement prescribed by the Deficit Reduction Act of 2005 (DRA). HR 5704, the Access to Medicare Imaging Act, is cosponsored by a broad bipartisan coalition of 42 representatives from across the country.

“A delay in the implementation of these cuts is essential in order to give Congress a chance to fully understand how cuts of this magnitude could affect Medicare beneficiaries’ access to imaging services,” Pitts said.

Section 5102 of the DRA, which President Bush signed into public law on February 8, calls for $2.8 billion to be cut from medical-imaging payments by 2011. If left intact, starting in 2007, the DRA will reduce reimbursement for the technical portion of imaging examinations by 25% over 2 years, and will cap reimbursement at freestanding imaging centers to the lesser amount of either the Hospital Outpatient Prospective Payment System (HOPPS) or the Medicare Part B Physician Fee Schedule (MPFS).

The DRA, already under fire because the House and Senate versions did not match at the time it was signed into law, is invoking ire from imaging professionals and patient advocacy groups alike. Section 5102 was not given due consideration, say organizations like the newly formed Access to Medical Imaging Coalition (AMIC), which represents more than 75,000 imaging professionals and counts among its proponents heavyweight groups like the American College of Radiology (ACR). Unresearched and dubiously substantiated, the section was passed without even the customary hearings with members of the medical community.

“The usual process is that you have hearings or markups, at which time there is debate among the members of the jurisdictional committees,” said Joshua Cooper, ACR senior director of government relations. “We believe that such a significant cut should have been subject to quite an intense debate.”

The Access to Medicare Imaging Act also calls for a comprehensive Government Accountability Office study to analyze the impact of the DRA payment methodology on patient access, particularly in rural and underserved areas.

Patient access is the subject at the forefront of AMIC’s initiative to see the cuts repealed. “Lack of access to appropriate imaging can contribute to late diagnosis, which, in turn, can lead to more costly, invasive, and intensive treatment,” said Nancy Davenport-Ennis, a member of AMIC, CEO of the National Patient Advocate Foundation, and a cancer survivor. “No one wants to undergo invasive surgeries, long-term hospitalizations, and loss of independence and functionality because they simply could not get to an imaging facility in a timely manner.”

Cooper elaborated, “We believe that a significant number of imaging facilities will severely reduce the availability of their services, if not close altogether, within a very short period of time. The other thing that we feel will happen is that procedures—such as mammography, which is primarily done in an office setting—will suffer. Even though they try to be tricky and exempt mammography from the reimbursement cuts, as any businessperson knows, if you’re facing massive cuts, you’re going to get rid of the procedures that aren’t making you as much money.”

The ACR urged Congress to look at the big picture. In a statement supporting HR 5704, it noted, “These drastic cuts may force many physicians to stop offering much needed imaging services or limit the number of Medicare patients they receive. They may also discourage research or development of new imaging technologies that are increasingly replacing more invasive (and more costly) techniques.”

Cooper anticipates action on the bill—one way or another—in October, prior to the elections, or else in a lame duck section in early December after the elections. “It’s most likely going to go down to the wire,” he said. “It’s all based on the availability of a bigger Medicare bill. This will not go as a stand-alone bill.”

—C. Vasko

HIMSS Analytics Launches State Health Care Reports

HIMSS Analytics LLC, Chicago, recently announced the launch of its new State Health Care Reports, which provide information on each state’s health care operations and economic environment. The reports cover general economics, such as revenues, population, and demographics; they also look at 16 different aspects of health care—from employment statistics and union listings to emergency preparedness and lists of regional health information organizations (RHIOs).

The information can be retrieved according to customizable criteria—data on all topics per state, for instance, or results from each state for one topic. RHIOs will be searchable by ZIP code.

“Companies targeting their solutions for health care in the United States need to understand the complex and diverse natures of each state’s environment to better position and market their products and services,” said Dave Garets, HIMSS Analytics president and CEO. “Our State Health Care Reports will highlight commonalities and differences in state health care operations. This information can help suppliers target their marketing strategies and positioning and packaging.”

Shown here as an example are data pertaining to Medicare and Medicaid in the state of Illinois. More information, including purchasing details, is available online at himssanalytics.org/ASP/ReportMart_Home.asp.

Illinois Medical Trends and Legislation
(Click image for large view)
Illinois Hospital Revenues
(Click image for large view)
Illinois Medicaid Spending
(Click image for large view)
Illinois Medicare Spending
(Click image for large view)