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 same day as another radiology procedure that included fluoroscopy. For example, code 76000 is not separately paid for when it is performed on the same day as a surgical procedure such as a cystoscopy. It is paid for, however, when performed as a stand-alone service (for example, as a sniff test).
Image-processing services: According to CMS, an image-processing service processes and integrates diagnostic-test data captured during another (independent) procedure, which is usually one that is paid for separately under HOPPS; 3D rendering falls into this category.
Intraoperative services: For 2008; CMS has packaged codes that are reported for supportive, dependent diagnostic testing (or other minor procedures) performed during independent procedures. Although these are referred to as intraoperative services, CMS clarifies that they may be provided in conjunction with a significant nonsurgical procedure, as well as with surgery. Examples of procedures affected by this packaging are intravascular ultrasound, endoscopic retrograde cholangiopancreatography, and nuclear-medicine ejection and wall-motion studies.
Imaging S&I: These codes have been packaged for 2008. They include the radiological S&I codes found in the radiology chapter of CPT, as well as codes 93555-93556, which represent imaging S&I services for cardiac catheterization.
Some of the S&I codes are unconditionally packaged. These represent services that would virtually always be performed in conjunction with a separately payable surgical procedure. For example, code 75982 is the S&I code for placement of an internal-external biliary-drainage catheter. The drainage procedure (47511) now includes payment for the imaging guidance; therefore, 75982 is unconditionally packaged.
Other S&I codes represent imaging that may be performed independently (not in conjunction with a separately payable surgical procedure). These S&I codes are conditionally packaged.
For example, an abdominal aortogram (code 75625) is a conditionally packaged service that is separately paid for only if there is no status-T procedure (a significant procedure to which multiple reduction applies) on the same day. If the aortogram is performed as a stand-alone diagnostic procedure, code 75625 is typically reported together with code 36200 (catheter placement in the aorta). Code 36200 is a status-N procedure (unconditionally packaged), so in this situation, payment will be made for 75625. If the patient undergoes a status-T surgical procedure on the same day (for example, femoral-popliteal angioplasty, 35474), then the aortogram is not paid for separately.
If multiple T-packaged services are performed on the same day, but not in conjunction with a status-T surgical procedure, CMS states that it will pay for one unit of the T-packaged service with the highest relative-payment weight. This means, for example, that if three arteriogram codes are reported on the same day and there is no status-T procedure performed, CMS will pay for only one arteriogram (the highest-paying study).
Diagnostic radiopharmaceuticals: For 2008, the HCPCS codes for diagnostic radiopharmaceuticals are unconditionally packaged. Payment for the radiopharmaceutical is considered to be included in the payment for the nuclear medicine examination for which it was administered.
CMS notes that many Medicare hospital outpatient claims for diagnostic nuclear-medicine studies are submitted without radiopharmaceutical HCPCS codes. For this reason, CMS has implemented new Outpatient Code Editor (OCE) edits that will return to the provider any claim for a nuclear-medicine examination that does not include an HCPCS code and a charge for the diagnostic radiopharmaceutical. These edits were added to the OCE effective January 1, 2008.
If the radiopharmaceutical is administered on a date prior to that of the actual imaging examination, CMS states that the hospital will need to hold the claim until after the service has been furnished, so that the radiopharmaceutical can appear on the same bill as the nuclear-medicine procedure.
Contrast agents: CMS, yet again, has changed the HCPCS codes for low-osmolar contrast media (LOCM). For 2008, there are only four LOCM codes instead of seven (see table).
| 2007 Code | 2008 Code | 2008 Description |
| Q9945 | Q9965 | LOCM, 100-199 mg/mL iodine concentration, per mL |
| Q9946 | Q9965 | LOCM, 100-199 mg/mL iodine concentration, per mL |
| Q9947 | Q9966 | LOCM, 200-299 mg/mL iodine concentration, per mL |
| Q9948 | Q9966 | LOCM, 200-299 mg/mL iodine concentration, per mL |
| Q9949 | Q9967 | LOCM, 300-399 mg/mL iodine concentration, per mL |
| Q9950 | Q9967 | LOCM, 300-399 mg/mL iodine concentration, per mL |
| Q9951 | No change | LOCM, 400 or more mg/mL iodine concentration, per mL |
2007 codes for low-osmolar contrast media (LOCM) with the new 2008 codes and their definitions.
In addition, all contrast agents are unconditionally packaged for 2008. Unconditionally packaged items are not paid separately by Medicare under any circumstances. This applies to the new contrast HCPCS codes as well as existing codes that were not deleted or modified for 2008.
2008 Procedure Coding Changes
There were a few changes to radiology procedure codes in 2008 that any individual involved in the coding process should be aware of to ensure accurate billing. Following is a summary of the key changes.
Chest tubes/thoracentesis: All of the procedure codes related to thoracentesis and chest-tube placement have been moved in the CPT manual and those for tube placement have been slightly modified; however, the code-definition modifications do not impact code assignment.
Central venous procedures: The blood-collection code for an implantable device was replaced with new code, and a new code was created for blood collection from an established central or peripheral catheter, not otherwise specified. In addition, 36550, which was used for declotting of a central venous catheter, has been replaced with 36593.
Gastrointestinal procedures: There were many revisions, deletions, and additions to the surgical and imaging codes for all gastrointestinal interventional procedures. This section contains the most significant changes for radiology for 2008. All of the new codes include fluoroscopic guidance, so there are no accompanying S&I codes.
It is not appropriate to report nasogastric tube placement (43752) for the inflation of the stomach prior to percutaneous gastrostomy-tube placement. This procedure is considered part of the procedure in this family of codes.
- 49440 is insertion of a gastrostomy tube, percutaneous, under fluoroscopic guidance, including contrast injection(s), image documentation, and report. For the conversion of a gastrostomy tube to a gastrojejunostomy tube at the time of initial gastrostomy tube placement, it is appropriate also to assign 49446.
- 49441 is insertion of a duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance, including contrast injection(s), imaging documentation, and report. This code is used for initial jejunostomy tube placement and not for a conversion from a gastrostomy tube to a gastrojejunostomy tube.
- 49442 is insertion of a cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance, including contrast injection(s), image documentation, and report.
- 49446 is conversion of a gastrostomy tube to a gastrojejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), imaging documentation, and report. If a gastrojejunostomy tube is placed at the initial encounter, both 49440 and 49446 should be assigned.
There are two new procedure codes, 49450-49451, to reflect the replacement of a gastrointestinal tube, depending on tube type. The existing code, 43760, was revised to indicate that a gastrostomy tube was replaced without imaging guidance. If an existing tube is removed and a new tube is placed via separate percutaneous access site, the procedure is considered to be a new tube placement (49440-49442) and not a replacement.
- A new code, 49460, was added to describe the mechanical removal of obstructive material from any type of gastrointestinal tube. If the tube is replaced, then this code may not be assigned.
- A new code, 49465, was added to describe a contrast injection of an existing gastrointestinal tube. This tube-check code should not be assigned for the contrast injection performed during initial tube placement.
CT/CT angiography (CTA): The procedure codes for CTA were all revised to remove the words "without contrast material(s)" and "further sections." The code format for all CTA codes now reads, "Computed tomographic angiography, with contrast material(s), including noncontrast images, if performed, and image postprocessing."
Cardiac MRI: The existing cardiac MRI codes (75552-75556) were deleted and replaced with restructured codes that combine function and morphology. Half of the codes describe noncontrast studies (75557-75560), and the remaining new codes describe combined contrast and noncontrast studies (75561-75564).
Ultrasound: Additional guidance has been provided regarding the appropriateness of billing for Doppler in addition to a regular ultrasound study. The evaluation of vascular structures using both color and spectral Doppler is separately reportable; however, color Doppler alone (when performed for anatomical-structure identification only) is not reported separately.
PET: Codes 78811-78816 were modified to remove the phrase “tumor imaging” to expand the conditions in which these codes may be used.
Compliance Update: New ABN on the Horizon
There is still a great deal of discussion in the health care community regarding self-referral guidelines, per-click arrangements, and other contractual issues. These compliance issues fall into the legal arena and are outside the scope of this article. Even outside these issues, there are many compliance concerns in radiology, and it is important to be aware of the types of issues that may affect your organization. One important change on the horizon is the implementation of a revised ABN.
An ABN is a written notice provided to a Medicare beneficiary, before services are furnished, when the provider believes that Medicare will not pay for some or all of the services on the basis that they are not reasonable and necessary. ABNs are not required for routine screening tests, which are (with very few exceptions, such as screening mammograms) statutorily excluded from coverage.
CMS is revising the ABN, which was last revised in 2002. The new form combines the current CMS-R-131-G and the CMS-R-131-L (for laboratory services) globally; wording changes were made throughout the ABN, as were adjustments in layout and formatting. One example is that the header label “(A) Supplier/Provider” is replaced by the more generic “Notifier,” since this term includes groups such as physicians, practitioners, and various provider and supplier types. Along with wording changes, there are some instructional changes.
The patient will now have these three options:- I want the service. You can collect the payment from me, but I also want you to bill Medicare for an official decision on payment.
- I want the service. You can collect from me. Do not bill Medicare.
- I do not want the service.
One major change is that the provider must include the estimated cost for all services covered by the ABN.
Currently, providers must use the official CMS ABN form (CMS R-131-G), which is available on the CMS Web site in both English and Spanish. This form contains fields for the service that the provider believes will be denied and for the reason that denial is expected.
ABNs cannot be used in a blanket manner for all Medicare patients. The provider must have reason to believe that a specific patient’s service will be denied. There is an exception to this rule for services with frequency limitations, such as screening mammograms. Because the provider may have no way of knowing for certain how long it has been since the patient’s last mammogram, it is permissible to issue an ABN to every Medicare patient presenting for a screening mammogram.
The ABN must indicate why the provider expects the service to be denied. For example, if the diagnosis provided by the referring physician does not meet the Local Coverage Determination criteria for the examination, the provider could indicate on the ABN that Medicare does not pay for this examination for the patient's condition.
When a signed ABN is on file for the procedure, modifier GA should be appended to any line items to which the ABN applies. If the service is then denied, the explanation of benefits will indicate that the patient received advance notice of noncoverage and is therefore financially responsible for the service. For hospital billing on a UB-04 claim form, the applicable occurrence codes and condition codes must also be reported.
Detailed instructions for the use of ABNs are available on the Beneficiary Notice Initiative page of the CMS Web site (see previously referenced link). All of this information should be carefully reviewed to ensure compliance with Medicare requirements.
I have no doubt that by the end of 2008, we will be discussing new reimbursement concerns, new 2009 procedure codes, and the implementation of new regulatory guidelines that may affect our operations. Radiology is an extremely exciting specialty, on the leading—and, sometimes, bleeding—edge, but the majority of us would agree that it is worth the time and effort to provide the highest-quality care, with a corresponding level of quality for our business practices.Melody Mulaik, MSHS, CPC, CPC-H, RCC, is president, Coding Strategies, Inc, a medical coding and compliance consulting firm based in Powder Springs, GA.
