Radiology Coding and Compliance for 2008

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Every year, radiology professionals who are responsible for ensuring the accuracy and compliance of coding and billing practices must do an internal assessment to ensure that their practices/organizations would withstand external scrutiny. In 2008, there continue to be many reimbursement, coding, and compliance challenges for radiology organizations. This article will address the key reimbursement and coding changes for 2008, as well as comment on the anticipated Advance Beneficiary Notice (ABN) schedule for future implementation.

Physician reimbursement: Under the Medicare Physician Fee Schedule, physicians, overall, have seen an increase of 0.5% over the 2007 conversion factor. When the practice-expense adjustment is taken into account, that number drops to -1.5% for interventional services and increases to 4.5% for PET/nuclear-medicine services. Unless Congress intervenes again, we will see the originally proposed 10.1% decrease go into effect on July 1, 2008. With the practice-expense adjustment, this will be an impact of -12.1% for interventional services and -6.1% for PET/nuclear medicine.

The Hospital Outpatient Prospective Payment System (HOPPS): 2008 has, unfortunately, brought us some of the greatest payment decreases ever experienced for radiology services. Even if you do not bill for facility services, it is important to understand the severity of these changes and how they may affect a hospital’s ability to justify financially the purchase of new equipment and/or certain types of supplies. Remember, the following information relates to facilities billing under HOPPS and not to entities billing with a CMS-1500.

Effective January 1, 2008, CMS implemented a number of important changes to its packaging policies under HOPPS. Packaging refers to the practice of making a single payment that includes payment for a significant procedure as well as the minor, ancillary services associated with the procedure. This is a reimbursement term, and it is very different from bundling, which is, in essence, a coding term. According to Medicare, even though separate payment may not be made for a packaged service, the procedure and/or supply should still be reported on the hospital’s claim form unless contraindicated by CPT® coding guidelines or Correct Coding Initiative edits. It is important that packaged services be listed on the hospital outpatient claim so that CMS can collect accurate data about the hospital’s costs.

There are new categories of packaged services; for 2008, CMS has packaged the following items and services:

  • guidance services,
  • image-processing services,
  • intraoperative services,
  • imaging supervision and interpretation (S &I) services,
  • diagnostic radiopharmaceuticals,
  • contrast media, and
  • observation services.

Some of these items and services are unconditionally packaged—that is, never separately paid for—while other services are conditionally packaged, so that separate payment may be made depending on what other services are provided on the same date. It is important to review this information in detail to ascertain the exact packaging guidelines for the services that you bill for routinely. You can find the Ambulatory Payment Classification status indicator for any procedure code by referring to the October 2007 version of the Addendum B file, available on the CMS Web site.

Guidance services: For 2008, CMS has packaged the image guidance codes for many radiology imaging procedures. Frequently encountered radiology examples include percutaneous breast clip placement (19295); fluoroscopy (76000-76001); ultrasound guidance for venous access (76937); all guidance codes for ablation (US-76940, CT-77013, and MR-77022); ultrasound guidance needle localization (76942); fluoroscopic guidance procedures (77001-77003); CT guidance for needle placement (77012); and stereotactic (77031) and mammographic (77032) guidance for breast biopsies.

All these codes except 76000 are unconditionally packaged—that is, separate payment will never be made for the imaging guidance. Instead, payment for the guidance is included in the payment for the associated procedure. For example, payment for a percutaneous liver biopsy (47000) includes payment for the ultrasound used to guide the biopsy (76942). Note that code 76942 should still be reported on the claim, even though it is not paid for separately.

Code 76000 (fluoroscopy) is conditionally packaged. Separate payment is not made for 76000 when it is reported on the