Radiology Coding

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Radiology Coding

  1. 1. Radiology Coding Keys for Successful Documentation, Compliance and Reimbursement July 31, 2008 Denver, Colorado
  2. 2. Panelists • Martin Auster, MD, MBA, Johns Hopkins University School of Medicine • Jeff Pilato, MHA, RTR, CPC-H, Health Record Services • Beth Friedman, RHIT, Health Record Services (presenting for Gerri Walk, RHIA, CCS-P)
  3. 3. The United Nations of Coding
  4. 4. Which hat do you wear?
  5. 5. Workshop Outline • Current state – Common methods of coding – New models of coding • Problems in radiology coding – Inadequate clinical documentation – Poor communication – Professional differences – Changing requirements
  6. 6. A Quick Overview OP Radiology • Goal is to provide clean claims • Small coding errors = big reimbursement problems • Biggest problems is coding accuracy • Six steps 1. Documentation 2. Codes and charges 3. Fee schedule 4. Medical necessity 5. CCI / OCE unbundling edits 6. Modifiers and incorrect linkages
  7. 7. Current State • Methods currently used for coding – Manual coding – Encoder coding – Computer-assisted coding – Combination / remote • Who is coding? – Radiology department – Medical records department (HIM) – Combination / outsourced
  8. 8. Management Models Model Pros Cons What You Need HIM performs all coding Already experienced general coders No medical necessity training Medical necessity workshop Radiology Dept. performs all coding Close to radiologists and techs Minimal coding training More coding training for Dx. Need qualified coders! RRS Radiology Dept. codes / HIM oversees Best of both Requires good relationship / division of duty Strong leadership and communication Outsource Experienced radiology coders. Steady flow (cash and coding) Not physically close to radiology Liaison
  9. 9. Case Study • Large, academic medical center in Midwest • 800 – 1,200 studies per day • Problem – Can’t find coders / space / salaries & benefits – Ramp up time for new hire • Solution – Outsource physician component – Certified, U.S. coders – Saved space/improved quality/experienced team
  10. 10. Tips for Success • Set expectations and needs upfront • Identify liaison on both sides • Review edit reports every day • Trend errors, partner to educate
  11. 11. How to Decide Which Model is Best for your Organization • Criteria that can be used: – Size of the practice, volume of cases, personnel, patient demographics, private practice vs. academic, hospital-based vs. imaging center
  12. 12. Workshop Outline • Current state – Common methods of coding – New models of coding • Problems in radiology coding – Inadequate clinical documentation – Poor communication – Professional differences – Changing requirements
  13. 13. The Clinical Documentation Deficit
  14. 14. The Impact of Insufficient Documentation • Lost revenue opportunities (under-coding) • Impact on quality scores and Healthgrades • Additional time spent by coders • Others
  15. 15. Impact on Revenue • Documentation concerns – Lack of clarity • Abdomen x-ray documented but lacking number of views – Ill-defined separate/additional procedures • With or without duplex scan – Single or multiple • NM cardiac blood pool studies
  16. 16. How to Improve Documentation • Radiologist perspective (Dr. Auster) • Radiology administrator perspective (Jeff) • HIM and coder perspective (Beth)
  17. 17. Radiologist Perspective • Examples of good and bad reporting – Show impact on reimbursement – Lump vs. split / bundle vs. package – Most don’t know • Train young radiologists how to dictate • Use standard report templates
  18. 18. Society of Interventional Radiology, Copyright 2008
  19. 19. ARCH ARTERIOGRAM
  20. 20. ARCH ANGIO
  21. 21. Society of Interventional Radiology, Copyright 2008
  22. 22. IVC FILTER PLACEMENT
  23. 23. Society of Interventional Radiology, Copyright 2008
  24. 24. ILIAC STENT PLACEMENT
  25. 25. ILIAC STENT PLACEMENT
  26. 26. Standard Report Templates National Guidelines for Radiology Reports American College of Radiology (ACR) General Information: Diagnosis Documentation Procedure Documentation Identification of patient Clinical hx, chronic conditions Signs, symptoms, reason for test If f/up test, f/up for what condition? Name and type of exam Referring physician Pertinent pos. and neg. findings Limited, mult. areas, complete or whole body test Date and time of procedure Impression and/or DX. Number and type of views taken (unilateral, bilateral, right, left) Comparative results (prior studies viewed for comparison) Do not use rule out, suspected, probable and/or questionable statements Type, amount and method of contrast media or radionuclide
  27. 27. General Information: Diagnosis Documentation Procedure Documentation Reason for test – sign or symptom Single or multiple determination, qualitative or quantitative Findings, results, impressions, conclusions Number of sequences or slices Limitations Poor film quality, patient body habitus, patient prep Radiologist signature Separate paragraphs with separate headings for mult. tests performed on one patient. Recommended f/up exam or diagnostic studies Standard Report Templates National Guidelines for Radiology Reports American College of Radiology (ACR)
  28. 28. Radiology Administrator Perspective • Put process in place for reimbursement and documentation issues – Assign the right person as liaison – Track and trend errors, focus program – Report back to lead radiologist for peer-to- peer education
  29. 29. Example Denial Log Date  Procedure  ProcCode  Rejection Reason  Action  Result  1/6/2008 Post op cxr  71010 Medical Necessity edit Replaced V670.9  (post‐op CXR) with  findings 5511.9  (effusion pleural NOS.)    Passed edit 2/14/08 3/10/2008 PET scan 78815 Medical Necessity edit Replaced 786.6 mass  in chest with reason  for test V10. 85  (personal history of  Brain ca.     passed edit on  3/20/08 3/16/2008 Mammogram  screening 77057 Medical Necessity edit Replaced V10.3  personal hx of breast  ca with V76.12  mammo screening passed edit on  3/20/08 4/12/2008 MRI of Brain  70544 Medical Necessity edit Codes correct  according to report.  Negative findings.  Checked with ordering  physician and 784.0  headache is correct  diagnosis.  No payment for  procedure 
  30. 30. HIM and Coder Perspective 1. Establish routine lines of communication with radiologists – Hold 15-minute lunch and learns with “like” group of radiologists • specific topic • explain what need • give real case examples with revenue impact
  31. 31. HIM and Coder Perspective 2. Get support from chief / lead radiologist 3. Establish goals and provide incentives 4. Standardize parameters for dictation 5. Get radiology involved in your CDI program
  32. 32. Communication
  33. 33. Radiologist Perspective • Learn how to interact with others – Radiologists, referring MDs, technicians, administrators, coders, and more • Hold combined meetings and talk about coding
  34. 34. We Act Like Islands, But We’re Not
  35. 35. Radiology Administrator Perspective • Know what is in your charge master, changes every year! • Get support from HIM – Understand how HIM operates – Understand coding roles / process • Understand reimbursement • Understand Local Coverage Determinations (LCDs)
  36. 36. CDM Updates • New CPT codes published annually in late summer or early fall – Must implement by January 1 • Includes: – Terminology updates (CPT 70496) – Deleted codes (CPT 74350) – New codes (CPT 49440) • Level III codes updated bi-annually
  37. 37. HIM and Coder Perspective • Establish radiology relationships and grow them – Include registration / business office too! • Monthly reports back to radiology • Stay educated and on top of new procedures
  38. 38. Workshop Outline • Current state – Common methods of coding – New models of coding • Problems in radiology coding – Inadequate clinical documentation – Poor communication – Professional differences – Changing requirements
  39. 39. Professional Differences • Radiology coders vs. HIM coders • Different Focus • Different Training • And Payor Differences! Radiology Today, “Clearing out the Cobwebs”, March 2008 Online at: www.healthrecordservices.com/news
  40. 40. Different Focus Radiology Coders HIM Coders Tips to Solve Focus on diagnosis and reviews procedure codes Focus on ICD-9-CM diagnosis. Focus on data for statistics and quality reporting. Lunch and learn for radiology coders about ICD-9-CM and quality initiatives. Limited outside review Under much scrutiny Both groups review OIG work plan and be aware of changes.
  41. 41. Procedure vs. Diagnosis Continued Radiology Coders HIM Coders Tips to Solve Procedure coding can be automated. Radiology role is to confirm / validate. Can review all available documents to code diagnosis. Employ trained, procedural coder in the radiology department. Will probably code both diagnosis and procedure. Need ICD-9-CM code for medical necessity Need ICD-9-CM code for medical necessity Establish query process with radiologists. Problem is usually ICD-9-CM diagnosis code for medical necessity. Radiology staff get caught in the middle!
  42. 42. Different Training Radiology Coders HIM Coders Tips to Solve Focused, Specific training on radiology only Broad, general training Encourage relationships between both sets of coders. Combine educational offerings.
  43. 43. And Payer Differences! • Vary by region/insurance carrier • Reasons for denials include: – Medical necessity (reason / justification for test) – Inaccurate CPT assignment – No and/or invalid modifier • Denials managed post-billing by trained specialist or auditor • Perform a pre-bill audit to decrease risk of denials (manual and automated edit process)
  44. 44. Radiologist Perspective • Re-evaluate traditional loss-leaders • Educate techs and administrators • Work with referring physicians • Be more active in managed care contract negotiations
  45. 45. Workshop Outline • Current state – Common methods of coding – New models of coding • Problems in radiology coding – Inadequate clinical documentation – Poor communication – Professional differences – Changing requirements
  46. 46. Changing Codes and Reimbursement…What’s Coming in 2009? • For All: Medicare focused on reducing costs – More bundling and more rules/edits for coding – Keep Medicare and OIG separate • For Hospitals: – OIG will focus on inappropriate payment for x-rays in ED – Medicare payments for beneficiaries with other insurance coverage – Recovery audit contractors (RAC) • For Physicians: – Focus on over-billing and inappropriate payment
  47. 47. More Packaging • Bundling is when one service is a component of another service – Example: 72132 CT of L sp with contrast includes 36000 injection of contrast • Packaging = Services that Medicare deems separate but included in other services – Example: placement of an internal-external biliary drainage catheter 47511 now includes the imaging guidance 75982.
  48. 48. Over the horizon…but be aware • Recovery audit contractors (RAC) • Medicare OP quality measures – Proposed measures for imaging efficiency • Other
  49. 49. Questions, Answers, Feedback Dr. Auster: mauster@jhmi.edu Gerri Walk: gerri@healthrecordservices.com Jeff Pilato: jeff@healthrecordservices.com Beth Friedman: beth@tfmgcom.com
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