A Dangerous Practice

Is compliance a good or a bad word inside your organization? Compliance is a good word when it helps ensure proper controls and boundaries are in place. Internal controls lead to more efficient and cost-effective radiology practices. A culture of compliance should be woven throughout the organization.  

As laws become more complex, practices must set aside time and funds for compliance education. Groups need to form and operate a compliance committee with a trusting environment in which all issues can be discussed freely, and root-cause analysis and corrective action plans can be initiated when needed.  

The tone for compliance should be set at the highest levels of governance within your organization. Leaders should be vigilant of the culture they want to establish. Staff should be encouraged to bring forth potential compliance issues. 

A prime example of a compliance landmine within billing is Place of Service (POS). It has been a couple of years since the Change Request (CR7631) clarifing POS policy was issued and later addressed in the CMS Manual Pub 100-04 effective January 1, 2016, yet POS still seems to be an issue throughout the country.  More groups are performing services across state lines (or more accurately in different CMS locales), so POS becomes a larger issue for radiology.  Let’s quickly review the rules.  

POS: A high-level review

When the technical and professional components are performed in two different Medicare localities, CMS guidelines require that they be billed separately with the appropriate modifiers.  For example, when a diagnostic test is performed in Indiana and the radiologist interprets the study in Florida, the technical component should be billed to the Indiana MAC and the professional component should be billed to the appropriate Florida MAC.  This not only impacts services that are performed across state lines but within the same state at different MAC locales. How have you set up your compliance controls to ensure proper billing to the appropriate MAC jurisdiction? 

Each group needs to decide how detailed their compliance audits should be when delving into POS. For instance, are you satisfied with the audit if the professional component (PC) and the technical component (TC) are billed correctly; or do you go a step further in the POS audit and look at the CMS 855I? Is the physician reading the study medically licensed in the jurisdiction that he/she is reading the study or just licensed in the state where the TC was performed?  

Yet another layer of complexity resides in the hospital’s perspective. In this set of facts, the hospital enters into a professional services contract with a radiology practice to perform professional interpretations.  The contract states that the hospital will bill globally for the service and the radiology group will bill a fixed fee to the hospital.   Does a potential billing compliance issue exist if the professional interpretation is performed in a different Medicare locale than the TC?  If so, how are the radiology groups and hospitals actually doing this? Should the radiology practice be concerned about POS from a hospital’s perspective?  

Going further with the audit, do you address the issue of whether the radiology practice is licensed to do business in the state, county or city that the professional interpretation is performed? In this example, the main radiology practice where the radiologist is employed is located in Indiana but the radiologist is actually residing and interpreting in Florida.  Presumably the radiology practice is licensed to do business in the state of Indiana but are they also licensed to do business in Florida?  Are they filing tax returns in both states?

Other minefields

POS issues are not the only potential roadblocks to radiology compliance. A few other billing compliance issues that you could look at within your compliance committee could include:

Point-of-service Collections: Point-of-service collections is one approach many providers have adopted to ensure that they receive their full contracted allowable amount when the reimbursement is being shared by the patient and the carrier.

It is important to have access to accurate benefit information to avoid overcharging the patient at time of service resulting in a patient refund.  State laws determine the length of time a practice has to refund overpayments to the patient; check with your state to ensure your policies are appropriate. 

Modifier 59: Modifier 59 was on the OIG worklist in 2005 and oftentimes still is being used incorrectly. Modifier 59 should only be appended when no other descriptive modifier is appropriate and should never be used to unbundle services for reimbursement purposes only.

In January 2015, CMS further defined modifier 59 by adding four additional subsets to this modifier to reduce the amount of misuse.

Treatment Orders and Radiology: Although a radiologist is considered a “treating physician” when performing a therapeutic interventional procedure, they are not considered so when performing a diagnostic interventional or diagnostic procedure.

A radiologist may not change a test ordered (i.e. from one modality to another) without obtaining a new order from the treating physician, except in a few cases.

Know your compliance.