If you are not familiar with the effects of ICD-9-CM diagnosis coding and CPT/HCPCS procedure coding on your practice, you may be losing out on the opportunity to report the clinical acuity of your patients and to receive correct reimbursement. The first step toward improvement is a basic understanding of the nuances of the two coding systems.
ICD-9-CM [International Classification of Diseases-Ninth Revision-Clinical Modification] is a clinical patient classification system, which the World Health Organization (WHO) oversees. ICD-9-CM codes are divided into groups called major diagnostic categories (MDCs). Examples of MDCs include respiratory conditions and cardiovascular conditions; each of these categories carries its own set of codes that describe most diagnoses or symptoms. Chapter 16 of the ICD-9-CM codebook gives a list of signs and symptoms, providing users with options when a clinical condition has yet to be ruled in or ruled out. For example, a physician palpates a mass in the left breast, but does not know if the mass is benign or malignant. A biopsy procedure is planned to determine if there is a malignancy. The preliminary diagnosis is a symptom of breast mass without further clinical characterization, and would be assigned a code from Chapter 16. After a definitive diagnosis is made, then a more specific diagnosis code would be assigned.
Within the next few years, the ICD-10-CM coding system will replace the ICD-9-CM in the United States. Other countries already use the ICD-10 instead of ICD-9-CM. The new system uses alphanumeric codes that offer more opportunities to describe a patient clinically.
The second coding system contains CPT/HCPCS codes designed by the American Medical Association (AMA) that are used to report procedures performed by physicians.
The AMA’s Current Procedural Terminology (CPT) system provides more specific procedure codes than the ICD-9-CM system and, in turn, better supports reimbursement methodologies. While CPT codes do provide a subtle improvement in the actual text description, many of them still lack the specificity needed to differentiate one procedure from another.
The HCPCS acronym stands for Health Care Financing Administration (HCFA) Common Procedures Coding System, which contains three levels of codes. Level I HCPCS codes are those listed in the AMA’s CPT codebook.
All other HCPCS codes are listed in level II (alphanumeric) or level III (local or regional codes). HCPCS codes provide a way to report more details of certain aspects of health care (eg, low osmolar contrast media, chemotherapy drugs, durable medical equipment, dental).
All told, these three coding systems are the mechanisms payors use to execute payments. CPT procedure codes, for example, link to a relative value unit (RVU) that contains values relating to practice expense, malpractice coverage costs, and skill levels. To appropriately request payments, providers must know in detail how to use them within their practice or in the hospital setting.
PATIENT ACUITY IS CRITICAL
In addition to having a basic understanding of the structure of the coding systems, providers also should be clear about the importance of using the most current versions of the codebooks. Using the most current codes is essential not only to report the services provided but also for patient acuity. Failure to report all pertinent conditions for a particular encounter or episode of care may lower the reimbursement issued.
More recently, payors have increased the squeeze on providers to code correctly. Essentially, this means asking a question for each case: Why was the patient here today? For a radiologist, the answer to this question is very important.
Although referring physicians have been put under the gun to provide an appropriate referral diagnosis to answer the above question, it is not always enough. We find that radiologists often must continue the clinical questioning of patients after they have arrived in the radiology suite. Far too often, the information the referring practitioner provided does not give enough data to proceed with the test.
Take, for example, a patient who is referred for a diagnostic radiograph of the lower leg. The referring diagnosis is leg problem, a diagnosis that cannot be coded under any circumstances. The information provided is vague and does not identify what the referring physician is looking for in terms of a diagnosis.
Therefore, radiologists have two options. Query the patient for more information, or contact the referring physician by phone for missing information. In the first option, the radiologist could ask the patient to describe the leg problem he or she is having and how long the condition has been present. However, the patient is not the optimal candidate to provide clinical referral information and may not be able to verbalize the reason the test was ordered.
In virtually all cases, a radiologist should contact the referring physician by phone to obtain additional information rather than interviewing the patient. After the additional clinical data have been collected, the radiologist has a better understanding as to why the patient was referred.
Unfortunately, this scenario presents a major problem: The referral diagnosis will not match the clinical indication the radiologist dictates on the procedure note.
LOCAL MEDICAL REVIEW POLICIES
Keeping in mind the above scenario, it is important to be aware of the Medicare program’s continual distribution of medical necessity guidelines. Physicians began receiving these notices around 1995 in their Medicare Part B bulletins, which include local medical review policies (LMRPs). Of the various LMRPs produced, many pertain to radiology services, including chest radiographs, bone density studies, and mammography.
The LMRP’s basic message is code correctly, or Medicare may not pay for the service. If a patient has been referred for a diagnostic test, and the referral diagnosis is not on the LMRP’s coverage list, no payment will be issued. However, providers may collect from the patient for services rendered even when Medicare considers the referral diagnosis noncovered. Medicare has instructed physicians and other providers to notify patients when a service is noncovered, and have them sign an advance beneficiary notice (ABN). The patient is then fiscally liable for the bill.
LMRPs have produced a risky method of managing receivables in terms of coding. Physicians and their employees sometimes believe that all diagnostic chest radiographs, for example, must have a medically necessary diagnosis. They make every effort to get the claim paid, including some that may not be appropriate (such as trying to find a covered diagnosis or diagnosis code). It is not acceptable to manufacture a diagnosis to get a claim paid.
In radiology, there is yet another complicated component to reimbursement. When radiologists intend to use nonionic media, they must officially interview the patients who will receive it. Be sure to document their answers on a standardized form and include the reason why the patient is not eligible for ionic contrast media.
Low osmolar contrast media criteria include certain allergies and chronic conditions that may cause adverse reactions in the patient. If conditions such as allergies are not coded correctly with ICD-9-CM, or are not listed as secondary diagnoses, the entire claim or at least a portion of it may be denied for payment.
How many radiologists are familiar with this guideline and practice the interview procedure routinely? It is not uncommon for radiology department staff to complete the majority of the interviews and then file the interview forms in the billing jackets. Forms that never get to the medical record place the hospital or radiology center at risk for nonpayment because no code has been assigned to the secondary diagnosis to justify the use of nonionic contrast media.
CAVEATS ON CUTTING CORNERS
In some practices, physicians believe that they can code their own diagnoses and procedures. They develop coding cheat sheets or adapt one from another practice whether the codes listed are right or wrong. They then proceed to code all cases without the assistance of an experienced or educated coding professional.
In such cases, the risk for claims denials is high as the diagnosis codes may be incorrect or the procedure codes are not accurately reported to reflect all aspects of the episode of care. Once again, physicians are at risk for reduced or nonpaid claims.
In general, cheat sheets for coding are less desirable than actual coding by the book. In many practices, though, coding sheets are a necessary evil due to a lack of educated support staff or a lack of time on the practitioner’s part to record the necessary information. Even when a cheat sheet is entirely accurate, many staff do not know how to use it or do not understand coding logistics. When that is the case, code assignments may be incorrect or incomplete, and, once again, the risk of lower or denied payment is demonstrated.
About 7 years ago, Medicare decided to change the reporting method for special or interventional radiology procedures. To this day, many radiology practices and hospitals do not totally understand the coding conventions for these procedures. As a result, many dollars remain uncollected, and the practice profile of the physician(s) is inaccurate.
Special procedures (such as stereotactic breast biopsies, percutaneous organ biopsies, and needle localizations) now require reporting the imaging component as well as the interventional or surgical component. The radiology fee schedule does not list these procedure components, so they must be priced using cost data, if possible. Payment for the surgical procedure component is made on the basis of the surgical CPT/HCPCS code reported.
Hospitals, which must follow the same reporting requirements, and physicians have taken far too long to catch on to these requirements, as far as officials at the Medicare program are concerned. The program recently took measures to notify providers that if they did not comply soon, they would be profiled for inappropriate reporting.
So how should radiology group practices handle the coding function?
If radiologists practice in a hospital setting, they will want to collaborate with the technical staff at the hospital to be sure the coding is correct for both parties. Radiologists who practice in a freestanding center will want to determine the correct method for reporting their work. In all cases, the point is to ensure that radiologist’s coding matches any technical component coding when appropriate.
Periodic monitoring of coding procedures for the practice is also important. Implement an internal data-quality audit program by choosing a number of radiology cases for coders, billers, and physicians to review. Use current Medicare reporting guidelines as a basis for the audit template. Review both diagnosis and procedure codes assigned for each encounter. Reference the dictated radiology report, any other applicable components of the medical record, and a copy of the claim generated for the payor.
Document the internal audit process, noting any reporting guidelines that apply to each case. This will demonstrate the physician’s awareness of certain reporting requirements and, hopefully, diminish the number of unpaid claims.
Although physicians must take the responsibility of overseeing the coding function within their practices, internal and external audit support may help them achieve reasonable audit trails. Practice coders and physicians must be familiar with common coding and reporting guidelines set forth by payors like Medicare or Blue Cross and should adhere to them.
Try to eliminate the practice of rebilling, as this tends to profile a physician or practice for possible poor coding policies or may create a suspect situation whereby the physician appears to be trying to maximize payments. Do it right the first time, and eliminate a potentially adverse profile.
If a practice is not receiving what is perceived as a fair market payment, the physician or practice manager should contact the payor to discuss options or contractual agreements to gain a better understanding of the payment methodology.
Radiologists should receive their fair market share of payments, but this cannot be accomplished without improving coding accuracy and acquiring a better understanding of the reporting rules. Profiles generated from claims databases are, simply, practice or provider profiles that are based in large part on the coded data received from the field. How well are you doing?
Lois Yoder, ART, CCS, and Roberta Anderson, RT, are with The enVision Group Inc, Naples, Fla, a resource management and consulting group.